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SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY: LONG-TERM FOLLOWUP RESULTS
0022-5347/04/1721-0076/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 76 – 80, July 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000132130.64727.b6
SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY: LONG-TERM FOLLOWUP RESULTS G. MUTO,* F. BARDARI, L. D’URSO
AND
C. GIONA
From the Department of Urology, S. Giovanni Bosco Hospital, Turin, Italy
ABSTRACT
Purpose: The efficacy of nerve sparing techniques to save potency in cystoprostatectomy is about 50%. This radical surgery may be proposed to young men with normal sexual function. We report the results of a 13-year experience with our innovative seminal sparing cystectomy and bladder replacement to maintain sexual function in such patients. Materials and Methods: Seminal sparing cystectomy is a modification of standard radical cystectomy in which the posterior bladder dissection is anterior to the seminal vesicle plane to preserve the vasa deferens, seminal vesicles, prostatic capsule and neurovascular bundles. Ablation of the whole bladder and the prostatic urothelium with surrounding hypertrophic tissue is guaranteed, and injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa is avoided. From April 1990 to December 2002 we performed 68 procedures in 63 patients (7 of whom were lost to followup) with superficial bladder cancer resistant to conservative therapies (18 patients with stage T1G2 disease, 13 TaG2, 11 T1G3 and 14 TaG3) and in 5 patients with invasive bladder cancer (T2G3) which was monofocal and away from the bladder neck. All patients had normal sexual function. A complete clinical evaluation (with prostate specific antigen [PSA], digital rectal examination and transrectal ultrasound) to exclude concomitant prostate cancer was performed. Average patient age was 49 years and mean followup was 68 months. Results: Normal erectile function was preserved in 58 patients (95%). Complete daytime continence was reached in 58 patients (95%) and nighttime continence was reached in 19 patients (31%). The early postoperative complication rate was 18% and the delayed complication rate was 26.2%. A total of 55 patients (90.2%) are alive and 6 patients (9.8%) died, 5 of cancer progression. High grade prostatic intraepithelial neoplasia was noticed in prostatic specimens in 3 patients and prostatic cancer was noted in 1 patient. These patients had a normal PSA before operation and a serum PSA less than 0.2 ng/ml at a mean followup of 19 months. No positive margins were identified on permanent histological analysis of the specimens, nor were local pelvic recurrences observed. Conclusions: Our innovative technique is safe, effective and easy to perform. The oncological and functional results obtained with a long followup justify seminal sparing cystectomy as an excellent surgical procedure which can be proposed to some oncological and nononcological cases. KEY WORDS: bladder neoplasms, cystectomy, urinary diversion, sexuality
seminal sparing cystectomy with an orthotopic bladder pouch.
Superficial bladder cancer includes a spectrum of cancers (Tis, Ta, T1) with markedly different biological potentials. Patients with multiple recurrences, despite the use of intravesical chemotherapeutic or immunotherapeutic agents, are most likely to have cancer progression. In the management of this group of patients the aim is to anticipate this progression when cystectomy is still curable. However, the radical operation may result in the loss of natural urethral voiding and normal sexual function with a consequent decrease in quality of life, especially in young patients. The development of orthotopic urinary diversion and nerve sparing techniques has decreased the loss of the natural preoperative state of these patients. However, in the best surgical hands potency maintenance is around 50%. To improve the preservation of sexual potency, since 1990 we have been developing a modified radical cystectomy, a “cysto-prostaticurethrectomy” instead of the standard cystoprostatectomy. We call this procedure
MATERIALS AND METHODS
In our department from April 1990 to December 2002 seminal sparing radical cystectomy was performed in 68 patients. The indication for surgery in 63 patients was superficial transitional cell carcinoma of the bladder (Ta–T1–Tis/G2–G3) which was recurrent (despite intravesical chemotherapy and/or immunoprophylaxis) and in 5 patients the indication was a monofocal T2G3 carcinoma of the anterior or lateral bladder wall. In the first group 7 patients were lost to followup. Therefore, we report the results of 61 patients. Average patient age at cystectomy was 49 years (range 36 to 68) and all patients had normal erectile function which they wished to maintain. Patients were evaluated by physical examination, chest x-ray, excretory urography and/or abdominal computerized tomography, routine serum chemistry studies (serum creatinine range 0.9 to 1.4 mg/ dl), prostate specific antigen (PSA) (range 0.8 to 3.4 ng/ml), transrectal ultrasound and cup biopsy of the prostatic urethra (negative for cancer) during the last transurethral resection (TUR). The surgery is performed through a lower midline transperitoneal incision. A bilateral pelvic lymph node dissection
Accepted for publication January 16, 2004. Nothing to disclose. * Correspondence: Corso Chieri, 29/c, Turin 10131, Italy (telephone: 011 2402235; FAX: 011 2402456; e-mail: [email protected]). Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 422 and 423. 76
SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY
77
is made, and the lymphatic tissue overlying the external iliac vessels and the obturator fossa are removed. No frozen section of this lymphatic tissue was made intraoperatively. Special care is taken to preserve the sympathetic fibers over the sacral promontory. As in a standard radical cystectomy, the vas deferens are bilaterally isolated, and the ureters indentified, isolated and transected near the entry in the posterior bladder wall. The posterior bladder wall and the portion of overlying peritoneum are dissected, and the obliterated umbilical artery and superior vesical arteries are transected bilaterally. At this point, usually in a traditional radical cystectomy, Denonvilliers’ fascia is opened and a blunt dissection behind the vas deferens is used to separate the rectum from the seminal vesicles and the prostate gland. In our procedure the level of the dissection is anterior to the seminal vesicles (fig. 1), leaving the vas deferens intact. The lateral pedicles of the bladder are dissected close to the bladder wall and the correct plane (between the posterior bladder surface, anteriorly, and between the seminal vesicle and ampullae of the vasa, posteriorly) is identified, reaching the cranial part of the prostatic capsule in its posterior and lateral position. Individual distal branches of the inferior vesical artery are transected during the isolation, but the neurovascular bundles and the posterior vessels of the hypogastric artery are untouched. The prostatic capsule is then incised and the hypertrophic prostatic tissue is isolated from the capsule with the same technique used in retropubic Millin prostatectomy. Finally, the prostatic urethra is carefully sectioned at the apex with scissors, and the bladder with the prostatic urethra and the surrounding hypertrophic prostatic tissue is removed en bloc (fig. 2).
FIG. 2. Prostatic urethra carefully sectioned with scissors at apex and bladder with urethra and surrounding hypertrophic tissue removed en bloc, leaving cuplike prostatic capsule and posterior plane intact.
FIG. 1. Section of plane of surgical dissection with scissors (represented by broken line). Posterior bladder wall is in front while seminal vesicles are to rear of dissection, and Denonvilliers’ fascia is not opened. Vas deferens are used as tracer markers to develop correct plane reaching prostatic capsule on posterior and lateral walls.
In young men this hypertrophic prostatic tissue is often poorly represented but the site of dissection between the prostatic capsule and the transitional zone of the gland is always readily apparent. No urinary spill can occur during this procedure since the bladder neck is removed in 1 piece with the prostatic tissue and the Foley catheter in situ. Sometimes hemostasis by electrocoagulation of the prostatic fossa is needed. Using this technique neurovascular bundles are never traumatized, stripped or coagulated and, after removing the bladder, the intact seminal plan with the bundles is clearly evident in the pelvis with the prostatic capsule exposed with a cuplike form. A mechanical detubularized Camey II ileal neobladder is performed and is anastomized to the prostatic capsule (ileocapsuloplasty) with 2-zero interrupted polyglactin sutures. A transurethral 20Fr Foley catheter is inserted before anastomosis is completed and the balloon is inflated in the prostatic fossa. In 3 cases the neobladder pouch was ileocecal with teniamyotomies using the Alcini procedure.1 The ureters are reimplanted with direct anastomosis and in a few cases with the serosal lined antireflux technique. The ureteral splints are removed after 10 to 12 days and the transurethral catheter is removed after 3 weeks. Patients were followed with physical examination and biochemical analysis 1 and 3 months after surgery, and then twice yearly. An abdominal and pelvic ultrasound evaluation was made after 3 months to check the kidneys and neobladder voiding, and then yearly. Computerized tomography of the abdomen and pelvis with urographic scan was assessed at 6 months and then alternated with an ultrasound evaluation yearly. Serum PSA evaluation and chest x-ray were performed yearly, and a complete urodynamic study of all patients was performed 6 months after surgery.
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TABLE 2. Early postoperative complications
The primary tumor stage of the 61 patients was T1G2 in 18, TaG2 in 13, T1G3 in 11, TaG3 in 14 and T2G3 in 5 patients (table 1). Only since February 2001, encouraged by the good functional and oncological results of this procedure, have we extended the indication to some invasive monofocal bladder cancers (5 cases of T2G3) of the dome or lateral wall. The time between the last transurethral resection and radical intervention was between 1 and 6 months. All patients were discharged from the hospital after an average of 21 days (range 14 to 38). Mean followup was 68 months (range 6 to 152) and 42 patients had a followup longer than 80 months. The overall morbidity was acceptable. The early postoperative complication rate was 18% in 11 patients (table 2).2 The delayed complication rate was 26.2% in 16 patients (table 3). A total of 55 patients (90.2%) are alive and 6 patients died (9.8%), 5 of cancer progression (table 4). Four patients with T2G3 (3 with pT2bG3pN0 and 1 with pT1G3pN0) were disease-free at a mean followup of 16 months (range 10 to 22) while the last patient with T2G3 (pT3bG3pN2) underwent systemic chemotherapy (gemcitabin and cisplatin). There were 3 patients with chronic renal failure (4.9%) and a Bricker undiversion was performed. Daytime continence was complete in 58 patients (95%) including the 3 aforementioned patients. Nighttime continence was perfect in 19 patients (31%) but the other 42 used pads or urinary condoms (including the 3 who underwent Bricker reoperations). One patient, 3 years after cystectomy, required clean intermittent autocatheterization due to a high post-voiding residual volume (more than 250 cc) with associated urethral reflux. Postoperative potency was clinically evaluated in all patients operated on after 1998 using the International Index of Erectile Function (the index was also retrospectively used for patients who had been operated on before 1998). Nighttime erection was still present 8 to 10 days after surgery in 49 patients (80.3%). A total of 55 patients (90.1%) had normal sexual function with adequate erections for sexual intercourse 1 to 2 months after surgery. In 3 patients (4.9%) the interval for recovery of normal erectile functions was longer (6 months). In 3 patients (4.9%) no spontaneous erections were noted and the patients used intracavernous injection of alprostadil for sexual intercourse. All patients had retrograde ejaculation and no evaluation of fertility was considered. In the prostatic specimens 3 high grade prostatic intraepithelial neoplasia (HGPIN) (4.9%) and 1 prostate cancer Gleason score 4 (1.6%) were found. All 4 of these patients had a normal serum PSA before cystectomy, and digital rectal examination and transrectal ultrasound were negative for prostate cancer. In these patients PSA at a mean followup of 19 months was less than 0.2 ng/ml (PSA serum level controlled every 6 months). Mean PSA level at 5 years after cystectomy was 0.7 ng/ml. TABLE 1. Patient cancer characteristics No. Pts
Primary Tumor Stage
Av No. Recurrences
Tumor Stage at Cystectomy
7 6 6 6 2 8 6 7 2 3 2 1 3 1 1
T1G2 T1G3 TaG3 TaG3 TaG3 T1G2 TaG2 TaG2 T1G3 T1G3 ⫹ carcinoma in situ T1G2 T1G2 T2G3 T2G3 T2G3
5 3 4 4 4 4 6 5 2 2 5 4 0 0 0
pT1G2 pT1G3 pTaG3 pT1G3 pT1G3 ⫹ Tis pT1G3 pT1G2 pT1G3 pT2aG3 pT1G3 ⫹ Tis pT0 pT1G2 ⫹ Tis pT2bG3 pN0 pT3bG3pN2 pT1G3 ⫹ Tis
No. Pts Wound infection Pneumonia Acute cholecystitis with sepsis Pneumonia embolism Transient ischemic attack Colitis by Clostridium difficile Urinary leakages from ileocapsuloanastomosis (2 resolved by longer drainage with indwelling urethral catheter, 1 resolved by endoscopic application of cyanoacrylic glue2) Neobladder-ileal fistula (resolved by endoscopic application of cyanoacrylic glue2)
1 1 1 1 1 2 3 1
TABLE 3. Late complications No. Pts Orthotopic neobladder calculi treated with endoscopic lithotripsy Ureteroileal strictures requiring percutaneous endoscopic dilation, 1 after ureteral reimplantation Strictures of prostatic fossa requiring TUR in 3 and holmium laser urethrotomy in 1 Ureteral reflux with no renal failure Renal failure with consequent Bricker undiversion (1 for ureteral reflux, 1 for anastomotic stenosis, 1 for rt nephroureterectomy for ureteral Ca and hydronephrosis) Alloplasty
5 2 4 1 3 1
TABLE 4. Characteristics of 6 deceased patients No. Pts pT1G3 hepatoca 60 mos later pTaG2 ⫹ Tis pulmonary metastasis 60 mos later (Bricker undiversion 3 mos before death) pT1G3 pulmonary metastasis 52 mos later 1pT1G3 ⫹ Tis pulmonary metastasis 38 mos later pT1G3 ⫹ Tis hepatic metastasis 20 mos later pT2G3 pulmonary and lymphatic metastasis 48 mos later (18 mos after cystectomy pulmonary metastasis treated with systemic methotrexate, vinblastine, doxorubicin and cisplatin chemotherapy and RC at 20 mos
1 1 1 1 1 1
DISCUSSION
There is a general consensus that superficial bladder cancers, which are refractory to conservative management, present a lifelong risk of stage progression and an upper tract tumor, especially in the high grade subgroup.3–5 Today it is not possible to identify accurately which superficial bladder cancer will fail to respond to intravesical therapy, and which of the recurrent cancers will progress to muscle invasive disease and/or metastasis. The biological natural history of superficial bladder cancer is unknown but the possible clinical down staging is clear.6, 7 The literature shows the risk of delaying cystectomy in such patients and an early radical approach is often recommended.8 –11 In fact radical cystectomy is highly effective in preventing tumor progression and in curing these patients. Moreover, we must also consider the anxiety of these patients and the consequent decrease in quality of life due to repeat TUR and intravesical instillation of drugs without success. In many cases there is also a worsening of storage (pelvic pain, urgency) and voiding systems (incontinence, strangury, dysuria) related to decreased bladder capacity and bladder oversensitivity. The concern for major lifestyle alterations attributed to radical cystectomy (especially in relation to sexual activity, urinary function and body image) has largely been decreased by the development of nerve sparing techniques and bladder replacement or continent urinary diversion. Schoenberg et al demonstrated that when performing nerve sparing radical cystoprostatectomy for organ confined cancer the disease specific 10-year survival rate for all stages treated was 69%, and the 10-year survival rate free of local recurrence was 94%, while recovery of sexual function was
SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY
age dependent (62% younger than 50 years, 47% between 50 and 60 years old, 20% older than 60 years).12 Therefore, the authors conclude that nerve sparing cystectomy coupled with orthotopic continent diversion may represent the best primary surgical approach for patients with organ confined bladder cancer, and probably represents the form of primary bladder cancer surgery and reconstruction to which bladder sparing protocols should be compared. In 1999 Hart et al reported their experience with the evaluation of long-term quality of life outcomes among 3 different urinary diversion groups (224 patients with ileal conduit, cutaneous or urethral pouch).13 No significant differences in quality of life appeared to be associated with the type of urinary diversion, although penile prosthesis placement was significantly associated with better sexual function and satisfaction, confirming the importance of erectile dysfunction in these male patients. In 1990 we started performing this modified radical cystectomy which we call “seminal sparing cystectomy” with orthotopic bladder replacement in the treatment of superficial bladder cancer recalcitrant to conservative management in a cohort of patients with normal sexual activity which they wanted to preserve. We reported our preliminary experience on a series of 42 patients in 199814 and only recently, based on the excellent oncological and functional results, have we extended the indication to some monofocal invasive bladder cancer of the lateral or anterior wall with no histologically confirmed involvement of the prostatic urethra. With our procedure of nerve sparing cystectomy autonomic innervation of the corpora cavernosa can be avoided by leaving the seminal vesicles and prostatic capsule in place and leaving the neurovascular bundles untouched. Therefore, 58 of the 61 patients in our series (95%) have preserved sexual potency with adequate erections for sexual intercourse without pharmacological help. Colombo et al recently published their similar favorable experience in a small group of 8 patients with a high risk of superficial bladder cancer and an 18-month mean followup.15 The operation, similar to ours, was different only in the prostatic approach because they performed a transurethral resection of the prostate from the bladder neck to the verumontanum as step 1 of the seminal sparing cystectomy, leaving the capsule intact for surgical step 2. All patients reported satisfactory sexual activity and morbidity was limited. Other similar favorable experiences were reported by Spitz et al16 with a personal technique preserving the vasa deferens, seminal vesicles, posterior prostate and neurovascular bundles in 4 patients with nonurothelial malignancy or nonmalignant bladder disease. In Horenblas et al’s provocative experience the indications were bladder cancer stages T1–T3 with absent tumor growth in the bladder neck in males and females, absent tumor in the prostatic urethra in males and absent invasive tumor in the trigone in female.17 They called the procedure “sexuality preserving cystectomy,” which consists of cystectomy alone with preservation of the vasa deferens, prostate and seminal vesicles in males, and all internal genitalia in females with the ileal neobladder anastomosed to the prostate in males and to the urethra in females. To focus on the importance of sexuality preservation in radical cystectomy of selected patients, in their introduction they wonder whether the prostate or internal female genitalia in some patients may indeed be spared, and ask whether the need to remove these organs has been sufficiently debated. With our procedure we completely remove the urothelium of the prostatic urethra with its surrounding hypertrophic tissue, if present, leaving only the prostatic capsule, not only for oncological reasons, but also to decrease urethral resistance of the orthotopic bladder pouch. In our series no positive margins were identified at permanent histological analysis of the specimens and no pelvic recurrences were
79
observed in the long-term followup while systemic cancer progression occurred in 5 patients (8.2%, only 1 with a G2 cancer). The morbidity rate was acceptable. In the prostatic specimens 3 cases of HGPIN and 1 prostate cancer were found, and in the last case no adjuvant therapy was started so as not to compromise sexual function. In all cases the PSA at a mean followup of 19 months was less than 0.2 ng/ml. The incidence of prostate cancer in cystoprostatectomy specimens is about 30% to 35% depending on age.18, 19 In our series HGPIN was noticed in 3 patients, 38, 59 and 68 years old, and prostate cancer was noted in a single 64-year-old patient. In all patients the complete clinical evaluation before intervention was negative. CONCLUSIONS
Our data related to modified radical cystectomy to preserve male sexual function. To date, with a mean followup of 68 months (range 6 to 152) this procedure has proven to be safe (no local recurrence) and effective (95% potency preservation). At the beginning of our experience the indication was restricted to patients with superficial bladder cancer refractory to conservative management, and patients who were highly motivated to protect sexual function. However, 2 years ago we extended this surgical procedure to invasive bladder cancer which is monofocal and away from the bladder neck. We believe that this procedure might be considered and proposed to some patients with urothelial and nonurothelial malignancies, and to those with a nonfunctioning bladder. We also believe that the possibility of fertility preservation should be evaluated. Correct patient selection and detailed informed consent are mandatory. Lucia Abbate provided the illustrations and Andrew Martin Garvey translated the paper into English. REFERENCES
1. Alcini, E., Racioppi, M., D’Addessi, A., Alcini, A., Menchinelli, P., Grassetti, F. et al: The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years’ experience. Br J Urol, 79: 333, 1997 2. Bardari, F., D’Urso, L. and Muto, G.: Conservative treatment of iatrogenic urinary fistulas: the value of cyanoacrylic glue. Urology, 58: 1046, 2001 3. Cookson, M. S., Herr, H. W., Zhang, Z.-F., Soloway, S., Sogani, P. C. and Fair, W. R.: The treated natural history of high risk superficial bladder cancer: 15-year outcome. J Urol, 158: 62, 1997 4. Holmang, S., Hedelin, H., Anderstrom, C. and Johansson, S. L.: The relationship among multiple recurrences, progression and prognosis of patients with stages Ta and T1 transitional cell cancer of the bladder followed for at least 20 years. J Urol, 153: 1823, 1995 5. Smith, J. A., Jr., Labasky, R. F., Cockett, A. T. K., Fracchia, J. A., Montie, J. E. and Rowland, R. G.: Bladder Cancer Clinical Guidelines Panel summary report on the management of nonmuscle invasive bladder cancer (stages Ta, T1 and TIS). J Urol, 162: 1697, 1999 6. Herr, H. W.: The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol, 162: 74, 1999 7. Vo¨ geli, T. A., Grimm, M.-O. and Ackermann, R.: Prospective study for quality control of TUR of bladder tumors by routine 2nd TUR (ReTUR). J Urol, suppl., 159: 143, abstract 543, 1998 8. Esrig, D., Freeman, J. A., Stein, J. P. and Skinner, D. G.: Early cystectomy for clinical stage T1 transitional cell carcinoma of the bladder. Semin Urol Oncol, 15: 154, 1997 9. Malkowicz, S. B., Nichols, P., Lieskovsky, G., Boyd, S. D., Huffman, J. and Skinner, D. G.: The role of radical cystectomy in the management of high grade superficial bladder cancer (PA, P1, PIS and P2). J Urol, 144: 641, 1990 10. Stockle, M., Alken, P., Engelmann, U., Jacobi, G. H., Riedmiller, H. and Hohenfellner, R.: Radical cystectomy– often too late? Eur Urol, 13: 361, 1987
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11. Stein, J. P.: Indications for early cystectomy. Semin Urol Oncol, 18: 289, 2000 12. Schoenberg, M. P., Walsh, P. C., Breazeale, D. R., Marshall, F. F., Mostwin, J. L. and Brendler, C. B.: Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup. J Urol, 155: 490, 1996 13. Hart, S., Skinner, E. C., Meyerowitz, B. E., Boyd, S., Lieskovsky, G. and Skinner, D. G.: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999 14. Muto, G. and Moroni, M.: Seminal-sparing cystectomy and ileocapsuloplasty. Acta Urol Ital, 12: 47, 1998 15. Colombo, R., Bertini, R., Salonia, A., Da Pozzo, L. F., Montorsi, F., Brausi, M. et al: Nerve and seminal sparing radical cystectomy with orthotopic urinary diversion for select patients with superficial bladder cancer: an innovative surgical approach. J Urol, 165: 51, 2001
16. Spitz, A., Stein, J. P., Lieskovsky, G. and Skinner, D. G.: Orthotopic urinary diversion with preservation of erectile and ejaculatory function in men requiring radical cystectomy for nonurothelial malignancy: a new technique. J Urol, 161: 1761, 1999 17. Horenblas, S., Meinhardt, W., Ijzerman, W. and Moonen, L. F. M.: Sexuality preserving cystectomy and neobladder: initial results. J Urol, 166: 837, 2001 18. Pritchett, T. R., Moreno, J., Warner, N. E., Lieskovsky, G., Nichols, P. W., Cook, B. A. et al: Unsuspected prostatic adenocarcinoma in patients who have undergone radical cystoprostatectomy for transitional cell carcinoma of the bladder. J Urol, 139: 1214, 1988 19. Moutzouris, G., Barbatis, C., Plastiras, D., Mertziotis, N., Katsifotis, C., Presvelos, V. et al: Incidence and histological findings of unsuspected prostatic adenocarcinoma in radical cystoprostatectomy for transitional cell carcinoma of the bladder. Scand J Urol Nephrol, 33: 27, 1999
Vol. 172, 76 – 80, July 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000132130.64727.b6
SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY: LONG-TERM FOLLOWUP RESULTS G. MUTO,* F. BARDARI, L. D’URSO
AND
C. GIONA
From the Department of Urology, S. Giovanni Bosco Hospital, Turin, Italy
ABSTRACT
Purpose: The efficacy of nerve sparing techniques to save potency in cystoprostatectomy is about 50%. This radical surgery may be proposed to young men with normal sexual function. We report the results of a 13-year experience with our innovative seminal sparing cystectomy and bladder replacement to maintain sexual function in such patients. Materials and Methods: Seminal sparing cystectomy is a modification of standard radical cystectomy in which the posterior bladder dissection is anterior to the seminal vesicle plane to preserve the vasa deferens, seminal vesicles, prostatic capsule and neurovascular bundles. Ablation of the whole bladder and the prostatic urothelium with surrounding hypertrophic tissue is guaranteed, and injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa is avoided. From April 1990 to December 2002 we performed 68 procedures in 63 patients (7 of whom were lost to followup) with superficial bladder cancer resistant to conservative therapies (18 patients with stage T1G2 disease, 13 TaG2, 11 T1G3 and 14 TaG3) and in 5 patients with invasive bladder cancer (T2G3) which was monofocal and away from the bladder neck. All patients had normal sexual function. A complete clinical evaluation (with prostate specific antigen [PSA], digital rectal examination and transrectal ultrasound) to exclude concomitant prostate cancer was performed. Average patient age was 49 years and mean followup was 68 months. Results: Normal erectile function was preserved in 58 patients (95%). Complete daytime continence was reached in 58 patients (95%) and nighttime continence was reached in 19 patients (31%). The early postoperative complication rate was 18% and the delayed complication rate was 26.2%. A total of 55 patients (90.2%) are alive and 6 patients (9.8%) died, 5 of cancer progression. High grade prostatic intraepithelial neoplasia was noticed in prostatic specimens in 3 patients and prostatic cancer was noted in 1 patient. These patients had a normal PSA before operation and a serum PSA less than 0.2 ng/ml at a mean followup of 19 months. No positive margins were identified on permanent histological analysis of the specimens, nor were local pelvic recurrences observed. Conclusions: Our innovative technique is safe, effective and easy to perform. The oncological and functional results obtained with a long followup justify seminal sparing cystectomy as an excellent surgical procedure which can be proposed to some oncological and nononcological cases. KEY WORDS: bladder neoplasms, cystectomy, urinary diversion, sexuality
seminal sparing cystectomy with an orthotopic bladder pouch.
Superficial bladder cancer includes a spectrum of cancers (Tis, Ta, T1) with markedly different biological potentials. Patients with multiple recurrences, despite the use of intravesical chemotherapeutic or immunotherapeutic agents, are most likely to have cancer progression. In the management of this group of patients the aim is to anticipate this progression when cystectomy is still curable. However, the radical operation may result in the loss of natural urethral voiding and normal sexual function with a consequent decrease in quality of life, especially in young patients. The development of orthotopic urinary diversion and nerve sparing techniques has decreased the loss of the natural preoperative state of these patients. However, in the best surgical hands potency maintenance is around 50%. To improve the preservation of sexual potency, since 1990 we have been developing a modified radical cystectomy, a “cysto-prostaticurethrectomy” instead of the standard cystoprostatectomy. We call this procedure
MATERIALS AND METHODS
In our department from April 1990 to December 2002 seminal sparing radical cystectomy was performed in 68 patients. The indication for surgery in 63 patients was superficial transitional cell carcinoma of the bladder (Ta–T1–Tis/G2–G3) which was recurrent (despite intravesical chemotherapy and/or immunoprophylaxis) and in 5 patients the indication was a monofocal T2G3 carcinoma of the anterior or lateral bladder wall. In the first group 7 patients were lost to followup. Therefore, we report the results of 61 patients. Average patient age at cystectomy was 49 years (range 36 to 68) and all patients had normal erectile function which they wished to maintain. Patients were evaluated by physical examination, chest x-ray, excretory urography and/or abdominal computerized tomography, routine serum chemistry studies (serum creatinine range 0.9 to 1.4 mg/ dl), prostate specific antigen (PSA) (range 0.8 to 3.4 ng/ml), transrectal ultrasound and cup biopsy of the prostatic urethra (negative for cancer) during the last transurethral resection (TUR). The surgery is performed through a lower midline transperitoneal incision. A bilateral pelvic lymph node dissection
Accepted for publication January 16, 2004. Nothing to disclose. * Correspondence: Corso Chieri, 29/c, Turin 10131, Italy (telephone: 011 2402235; FAX: 011 2402456; e-mail: [email protected]). Editor’s Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 422 and 423. 76
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77
is made, and the lymphatic tissue overlying the external iliac vessels and the obturator fossa are removed. No frozen section of this lymphatic tissue was made intraoperatively. Special care is taken to preserve the sympathetic fibers over the sacral promontory. As in a standard radical cystectomy, the vas deferens are bilaterally isolated, and the ureters indentified, isolated and transected near the entry in the posterior bladder wall. The posterior bladder wall and the portion of overlying peritoneum are dissected, and the obliterated umbilical artery and superior vesical arteries are transected bilaterally. At this point, usually in a traditional radical cystectomy, Denonvilliers’ fascia is opened and a blunt dissection behind the vas deferens is used to separate the rectum from the seminal vesicles and the prostate gland. In our procedure the level of the dissection is anterior to the seminal vesicles (fig. 1), leaving the vas deferens intact. The lateral pedicles of the bladder are dissected close to the bladder wall and the correct plane (between the posterior bladder surface, anteriorly, and between the seminal vesicle and ampullae of the vasa, posteriorly) is identified, reaching the cranial part of the prostatic capsule in its posterior and lateral position. Individual distal branches of the inferior vesical artery are transected during the isolation, but the neurovascular bundles and the posterior vessels of the hypogastric artery are untouched. The prostatic capsule is then incised and the hypertrophic prostatic tissue is isolated from the capsule with the same technique used in retropubic Millin prostatectomy. Finally, the prostatic urethra is carefully sectioned at the apex with scissors, and the bladder with the prostatic urethra and the surrounding hypertrophic prostatic tissue is removed en bloc (fig. 2).
FIG. 2. Prostatic urethra carefully sectioned with scissors at apex and bladder with urethra and surrounding hypertrophic tissue removed en bloc, leaving cuplike prostatic capsule and posterior plane intact.
FIG. 1. Section of plane of surgical dissection with scissors (represented by broken line). Posterior bladder wall is in front while seminal vesicles are to rear of dissection, and Denonvilliers’ fascia is not opened. Vas deferens are used as tracer markers to develop correct plane reaching prostatic capsule on posterior and lateral walls.
In young men this hypertrophic prostatic tissue is often poorly represented but the site of dissection between the prostatic capsule and the transitional zone of the gland is always readily apparent. No urinary spill can occur during this procedure since the bladder neck is removed in 1 piece with the prostatic tissue and the Foley catheter in situ. Sometimes hemostasis by electrocoagulation of the prostatic fossa is needed. Using this technique neurovascular bundles are never traumatized, stripped or coagulated and, after removing the bladder, the intact seminal plan with the bundles is clearly evident in the pelvis with the prostatic capsule exposed with a cuplike form. A mechanical detubularized Camey II ileal neobladder is performed and is anastomized to the prostatic capsule (ileocapsuloplasty) with 2-zero interrupted polyglactin sutures. A transurethral 20Fr Foley catheter is inserted before anastomosis is completed and the balloon is inflated in the prostatic fossa. In 3 cases the neobladder pouch was ileocecal with teniamyotomies using the Alcini procedure.1 The ureters are reimplanted with direct anastomosis and in a few cases with the serosal lined antireflux technique. The ureteral splints are removed after 10 to 12 days and the transurethral catheter is removed after 3 weeks. Patients were followed with physical examination and biochemical analysis 1 and 3 months after surgery, and then twice yearly. An abdominal and pelvic ultrasound evaluation was made after 3 months to check the kidneys and neobladder voiding, and then yearly. Computerized tomography of the abdomen and pelvis with urographic scan was assessed at 6 months and then alternated with an ultrasound evaluation yearly. Serum PSA evaluation and chest x-ray were performed yearly, and a complete urodynamic study of all patients was performed 6 months after surgery.
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SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY RESULTS
TABLE 2. Early postoperative complications
The primary tumor stage of the 61 patients was T1G2 in 18, TaG2 in 13, T1G3 in 11, TaG3 in 14 and T2G3 in 5 patients (table 1). Only since February 2001, encouraged by the good functional and oncological results of this procedure, have we extended the indication to some invasive monofocal bladder cancers (5 cases of T2G3) of the dome or lateral wall. The time between the last transurethral resection and radical intervention was between 1 and 6 months. All patients were discharged from the hospital after an average of 21 days (range 14 to 38). Mean followup was 68 months (range 6 to 152) and 42 patients had a followup longer than 80 months. The overall morbidity was acceptable. The early postoperative complication rate was 18% in 11 patients (table 2).2 The delayed complication rate was 26.2% in 16 patients (table 3). A total of 55 patients (90.2%) are alive and 6 patients died (9.8%), 5 of cancer progression (table 4). Four patients with T2G3 (3 with pT2bG3pN0 and 1 with pT1G3pN0) were disease-free at a mean followup of 16 months (range 10 to 22) while the last patient with T2G3 (pT3bG3pN2) underwent systemic chemotherapy (gemcitabin and cisplatin). There were 3 patients with chronic renal failure (4.9%) and a Bricker undiversion was performed. Daytime continence was complete in 58 patients (95%) including the 3 aforementioned patients. Nighttime continence was perfect in 19 patients (31%) but the other 42 used pads or urinary condoms (including the 3 who underwent Bricker reoperations). One patient, 3 years after cystectomy, required clean intermittent autocatheterization due to a high post-voiding residual volume (more than 250 cc) with associated urethral reflux. Postoperative potency was clinically evaluated in all patients operated on after 1998 using the International Index of Erectile Function (the index was also retrospectively used for patients who had been operated on before 1998). Nighttime erection was still present 8 to 10 days after surgery in 49 patients (80.3%). A total of 55 patients (90.1%) had normal sexual function with adequate erections for sexual intercourse 1 to 2 months after surgery. In 3 patients (4.9%) the interval for recovery of normal erectile functions was longer (6 months). In 3 patients (4.9%) no spontaneous erections were noted and the patients used intracavernous injection of alprostadil for sexual intercourse. All patients had retrograde ejaculation and no evaluation of fertility was considered. In the prostatic specimens 3 high grade prostatic intraepithelial neoplasia (HGPIN) (4.9%) and 1 prostate cancer Gleason score 4 (1.6%) were found. All 4 of these patients had a normal serum PSA before cystectomy, and digital rectal examination and transrectal ultrasound were negative for prostate cancer. In these patients PSA at a mean followup of 19 months was less than 0.2 ng/ml (PSA serum level controlled every 6 months). Mean PSA level at 5 years after cystectomy was 0.7 ng/ml. TABLE 1. Patient cancer characteristics No. Pts
Primary Tumor Stage
Av No. Recurrences
Tumor Stage at Cystectomy
7 6 6 6 2 8 6 7 2 3 2 1 3 1 1
T1G2 T1G3 TaG3 TaG3 TaG3 T1G2 TaG2 TaG2 T1G3 T1G3 ⫹ carcinoma in situ T1G2 T1G2 T2G3 T2G3 T2G3
5 3 4 4 4 4 6 5 2 2 5 4 0 0 0
pT1G2 pT1G3 pTaG3 pT1G3 pT1G3 ⫹ Tis pT1G3 pT1G2 pT1G3 pT2aG3 pT1G3 ⫹ Tis pT0 pT1G2 ⫹ Tis pT2bG3 pN0 pT3bG3pN2 pT1G3 ⫹ Tis
No. Pts Wound infection Pneumonia Acute cholecystitis with sepsis Pneumonia embolism Transient ischemic attack Colitis by Clostridium difficile Urinary leakages from ileocapsuloanastomosis (2 resolved by longer drainage with indwelling urethral catheter, 1 resolved by endoscopic application of cyanoacrylic glue2) Neobladder-ileal fistula (resolved by endoscopic application of cyanoacrylic glue2)
1 1 1 1 1 2 3 1
TABLE 3. Late complications No. Pts Orthotopic neobladder calculi treated with endoscopic lithotripsy Ureteroileal strictures requiring percutaneous endoscopic dilation, 1 after ureteral reimplantation Strictures of prostatic fossa requiring TUR in 3 and holmium laser urethrotomy in 1 Ureteral reflux with no renal failure Renal failure with consequent Bricker undiversion (1 for ureteral reflux, 1 for anastomotic stenosis, 1 for rt nephroureterectomy for ureteral Ca and hydronephrosis) Alloplasty
5 2 4 1 3 1
TABLE 4. Characteristics of 6 deceased patients No. Pts pT1G3 hepatoca 60 mos later pTaG2 ⫹ Tis pulmonary metastasis 60 mos later (Bricker undiversion 3 mos before death) pT1G3 pulmonary metastasis 52 mos later 1pT1G3 ⫹ Tis pulmonary metastasis 38 mos later pT1G3 ⫹ Tis hepatic metastasis 20 mos later pT2G3 pulmonary and lymphatic metastasis 48 mos later (18 mos after cystectomy pulmonary metastasis treated with systemic methotrexate, vinblastine, doxorubicin and cisplatin chemotherapy and RC at 20 mos
1 1 1 1 1 1
DISCUSSION
There is a general consensus that superficial bladder cancers, which are refractory to conservative management, present a lifelong risk of stage progression and an upper tract tumor, especially in the high grade subgroup.3–5 Today it is not possible to identify accurately which superficial bladder cancer will fail to respond to intravesical therapy, and which of the recurrent cancers will progress to muscle invasive disease and/or metastasis. The biological natural history of superficial bladder cancer is unknown but the possible clinical down staging is clear.6, 7 The literature shows the risk of delaying cystectomy in such patients and an early radical approach is often recommended.8 –11 In fact radical cystectomy is highly effective in preventing tumor progression and in curing these patients. Moreover, we must also consider the anxiety of these patients and the consequent decrease in quality of life due to repeat TUR and intravesical instillation of drugs without success. In many cases there is also a worsening of storage (pelvic pain, urgency) and voiding systems (incontinence, strangury, dysuria) related to decreased bladder capacity and bladder oversensitivity. The concern for major lifestyle alterations attributed to radical cystectomy (especially in relation to sexual activity, urinary function and body image) has largely been decreased by the development of nerve sparing techniques and bladder replacement or continent urinary diversion. Schoenberg et al demonstrated that when performing nerve sparing radical cystoprostatectomy for organ confined cancer the disease specific 10-year survival rate for all stages treated was 69%, and the 10-year survival rate free of local recurrence was 94%, while recovery of sexual function was
SEMINAL SPARING CYSTECTOMY AND ILEOCAPSULOPLASTY
age dependent (62% younger than 50 years, 47% between 50 and 60 years old, 20% older than 60 years).12 Therefore, the authors conclude that nerve sparing cystectomy coupled with orthotopic continent diversion may represent the best primary surgical approach for patients with organ confined bladder cancer, and probably represents the form of primary bladder cancer surgery and reconstruction to which bladder sparing protocols should be compared. In 1999 Hart et al reported their experience with the evaluation of long-term quality of life outcomes among 3 different urinary diversion groups (224 patients with ileal conduit, cutaneous or urethral pouch).13 No significant differences in quality of life appeared to be associated with the type of urinary diversion, although penile prosthesis placement was significantly associated with better sexual function and satisfaction, confirming the importance of erectile dysfunction in these male patients. In 1990 we started performing this modified radical cystectomy which we call “seminal sparing cystectomy” with orthotopic bladder replacement in the treatment of superficial bladder cancer recalcitrant to conservative management in a cohort of patients with normal sexual activity which they wanted to preserve. We reported our preliminary experience on a series of 42 patients in 199814 and only recently, based on the excellent oncological and functional results, have we extended the indication to some monofocal invasive bladder cancer of the lateral or anterior wall with no histologically confirmed involvement of the prostatic urethra. With our procedure of nerve sparing cystectomy autonomic innervation of the corpora cavernosa can be avoided by leaving the seminal vesicles and prostatic capsule in place and leaving the neurovascular bundles untouched. Therefore, 58 of the 61 patients in our series (95%) have preserved sexual potency with adequate erections for sexual intercourse without pharmacological help. Colombo et al recently published their similar favorable experience in a small group of 8 patients with a high risk of superficial bladder cancer and an 18-month mean followup.15 The operation, similar to ours, was different only in the prostatic approach because they performed a transurethral resection of the prostate from the bladder neck to the verumontanum as step 1 of the seminal sparing cystectomy, leaving the capsule intact for surgical step 2. All patients reported satisfactory sexual activity and morbidity was limited. Other similar favorable experiences were reported by Spitz et al16 with a personal technique preserving the vasa deferens, seminal vesicles, posterior prostate and neurovascular bundles in 4 patients with nonurothelial malignancy or nonmalignant bladder disease. In Horenblas et al’s provocative experience the indications were bladder cancer stages T1–T3 with absent tumor growth in the bladder neck in males and females, absent tumor in the prostatic urethra in males and absent invasive tumor in the trigone in female.17 They called the procedure “sexuality preserving cystectomy,” which consists of cystectomy alone with preservation of the vasa deferens, prostate and seminal vesicles in males, and all internal genitalia in females with the ileal neobladder anastomosed to the prostate in males and to the urethra in females. To focus on the importance of sexuality preservation in radical cystectomy of selected patients, in their introduction they wonder whether the prostate or internal female genitalia in some patients may indeed be spared, and ask whether the need to remove these organs has been sufficiently debated. With our procedure we completely remove the urothelium of the prostatic urethra with its surrounding hypertrophic tissue, if present, leaving only the prostatic capsule, not only for oncological reasons, but also to decrease urethral resistance of the orthotopic bladder pouch. In our series no positive margins were identified at permanent histological analysis of the specimens and no pelvic recurrences were
79
observed in the long-term followup while systemic cancer progression occurred in 5 patients (8.2%, only 1 with a G2 cancer). The morbidity rate was acceptable. In the prostatic specimens 3 cases of HGPIN and 1 prostate cancer were found, and in the last case no adjuvant therapy was started so as not to compromise sexual function. In all cases the PSA at a mean followup of 19 months was less than 0.2 ng/ml. The incidence of prostate cancer in cystoprostatectomy specimens is about 30% to 35% depending on age.18, 19 In our series HGPIN was noticed in 3 patients, 38, 59 and 68 years old, and prostate cancer was noted in a single 64-year-old patient. In all patients the complete clinical evaluation before intervention was negative. CONCLUSIONS
Our data related to modified radical cystectomy to preserve male sexual function. To date, with a mean followup of 68 months (range 6 to 152) this procedure has proven to be safe (no local recurrence) and effective (95% potency preservation). At the beginning of our experience the indication was restricted to patients with superficial bladder cancer refractory to conservative management, and patients who were highly motivated to protect sexual function. However, 2 years ago we extended this surgical procedure to invasive bladder cancer which is monofocal and away from the bladder neck. We believe that this procedure might be considered and proposed to some patients with urothelial and nonurothelial malignancies, and to those with a nonfunctioning bladder. We also believe that the possibility of fertility preservation should be evaluated. Correct patient selection and detailed informed consent are mandatory. Lucia Abbate provided the illustrations and Andrew Martin Garvey translated the paper into English. REFERENCES
1. Alcini, E., Racioppi, M., D’Addessi, A., Alcini, A., Menchinelli, P., Grassetti, F. et al: The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years’ experience. Br J Urol, 79: 333, 1997 2. Bardari, F., D’Urso, L. and Muto, G.: Conservative treatment of iatrogenic urinary fistulas: the value of cyanoacrylic glue. Urology, 58: 1046, 2001 3. Cookson, M. S., Herr, H. W., Zhang, Z.-F., Soloway, S., Sogani, P. C. and Fair, W. R.: The treated natural history of high risk superficial bladder cancer: 15-year outcome. J Urol, 158: 62, 1997 4. Holmang, S., Hedelin, H., Anderstrom, C. and Johansson, S. L.: The relationship among multiple recurrences, progression and prognosis of patients with stages Ta and T1 transitional cell cancer of the bladder followed for at least 20 years. J Urol, 153: 1823, 1995 5. Smith, J. A., Jr., Labasky, R. F., Cockett, A. T. K., Fracchia, J. A., Montie, J. E. and Rowland, R. G.: Bladder Cancer Clinical Guidelines Panel summary report on the management of nonmuscle invasive bladder cancer (stages Ta, T1 and TIS). J Urol, 162: 1697, 1999 6. Herr, H. W.: The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol, 162: 74, 1999 7. Vo¨ geli, T. A., Grimm, M.-O. and Ackermann, R.: Prospective study for quality control of TUR of bladder tumors by routine 2nd TUR (ReTUR). J Urol, suppl., 159: 143, abstract 543, 1998 8. Esrig, D., Freeman, J. A., Stein, J. P. and Skinner, D. G.: Early cystectomy for clinical stage T1 transitional cell carcinoma of the bladder. Semin Urol Oncol, 15: 154, 1997 9. Malkowicz, S. B., Nichols, P., Lieskovsky, G., Boyd, S. D., Huffman, J. and Skinner, D. G.: The role of radical cystectomy in the management of high grade superficial bladder cancer (PA, P1, PIS and P2). J Urol, 144: 641, 1990 10. Stockle, M., Alken, P., Engelmann, U., Jacobi, G. H., Riedmiller, H. and Hohenfellner, R.: Radical cystectomy– often too late? Eur Urol, 13: 361, 1987
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11. Stein, J. P.: Indications for early cystectomy. Semin Urol Oncol, 18: 289, 2000 12. Schoenberg, M. P., Walsh, P. C., Breazeale, D. R., Marshall, F. F., Mostwin, J. L. and Brendler, C. B.: Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup. J Urol, 155: 490, 1996 13. Hart, S., Skinner, E. C., Meyerowitz, B. E., Boyd, S., Lieskovsky, G. and Skinner, D. G.: Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162: 77, 1999 14. Muto, G. and Moroni, M.: Seminal-sparing cystectomy and ileocapsuloplasty. Acta Urol Ital, 12: 47, 1998 15. Colombo, R., Bertini, R., Salonia, A., Da Pozzo, L. F., Montorsi, F., Brausi, M. et al: Nerve and seminal sparing radical cystectomy with orthotopic urinary diversion for select patients with superficial bladder cancer: an innovative surgical approach. J Urol, 165: 51, 2001
16. Spitz, A., Stein, J. P., Lieskovsky, G. and Skinner, D. G.: Orthotopic urinary diversion with preservation of erectile and ejaculatory function in men requiring radical cystectomy for nonurothelial malignancy: a new technique. J Urol, 161: 1761, 1999 17. Horenblas, S., Meinhardt, W., Ijzerman, W. and Moonen, L. F. M.: Sexuality preserving cystectomy and neobladder: initial results. J Urol, 166: 837, 2001 18. Pritchett, T. R., Moreno, J., Warner, N. E., Lieskovsky, G., Nichols, P. W., Cook, B. A. et al: Unsuspected prostatic adenocarcinoma in patients who have undergone radical cystoprostatectomy for transitional cell carcinoma of the bladder. J Urol, 139: 1214, 1988 19. Moutzouris, G., Barbatis, C., Plastiras, D., Mertziotis, N., Katsifotis, C., Presvelos, V. et al: Incidence and histological findings of unsuspected prostatic adenocarcinoma in radical cystoprostatectomy for transitional cell carcinoma of the bladder. Scand J Urol Nephrol, 33: 27, 1999