The use of neobladders in women undergoing cystectomy for transitional-cell cancer

Factors That Influence Selectionof Urinary Diversion Among Bladder Cancer Patients in 3 Community-based Integrated Health Care Systems

OBJECTIVE

To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk nonmuscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options.

METHODS

Bladder cancer patients' age ≥21 years with cystectomy/UD performed from January 2010 to June 2015 in 3 Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect.

RESULTS

Of 991 eligible patients, 794 (80%) received IC. One hundred sixty-nine surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (intraclass correlation coefficient = 0.26). The multilevel model with only patient factors showed good fit (area under the curve = 0.93, Hosmer-Lemeshow test P = .44), and older age, female sex, estimated glomerular filtration rate <45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs neobladder/continent pouch. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (P = .29).

CONCLUSION

In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.

Urinary retention after orthotopic neobladder substitution in females

PURPOSE

Urinary retention is a common complication after orthotopic neobladder urinary diversion. We reviewed a case series of women who underwent neobladder creation and discuss anatomical findings, and urinary retention etiology and prevention.

MATERIALS AND METHODS

We retrospectively reviewed the records of all orthotopic neobladder urinary diversions in female patients performed at our institution from 1999 through 2010. We abstracted baseline clinical and demographic characteristics, operative information, and postoperative clinical, urodynamic, imaging and secondary procedure followup. We defined urinary retention as the need for intermittent catheterization.

RESULTS

We identified 21 female patients who underwent neobladder diversion. Median age at cystectomy was 62 years (range 43 to 77). Median followup was 3 years (range 3 to 138 months). Of the patients 14 underwent ileocolic diversion, 6 underwent Studer ileal diversion and 1 underwent preservation of a right colon augmentation. All patients underwent prior or concurrent hysterectomy. In 2 patients with a history of genitourinary tuberculosis neobladder-vaginal fistulas developed postoperatively and they were excluded from analysis. Of the 19 female patients with a neobladder included in analysis 7 (36.8%) experienced urinary retention requiring clean intermittent catheterization. Associated abnormalities included neocystocele formation in 6 cases, anastomotic stricture in 1 and progressive neurological disease in 1. Upon straining the average neobladder descent was approximately 2 cm and the average change in the neocystourethral angle in patients with neocystoceles was 18 degrees. Of the patients 11 (57.9%) had a nonobstructive voiding pattern.

CONCLUSIONS

Urinary retention in female patients with a neobladder can be functional, anatomical or multifactorial. In our series common anatomical findings associated with urinary retention were neocystocele formation and urethral kinking.

Radical cystectomy and orthotopic bladder substitution using ileum

Over the past decade, continent urinary diversion, especially orthotopic bladder substitutions, has become increasingly popular following radical cystectomy for bladder cancer. The ultimate goal of orthotopic bladder substitution is to offer patients the best quality of life, similar to that of patients with native bladders. To achieve that purpose, surgeons should be familiar with the characteristics of good candidates for neobladders, the possible intraoperative and postoperative problems related to the surgery, and the solutions to these problems. Postoperative surveillance and instructions given to the patients also contribute to successful, functional results. Here, we reviewed the indications, pitfalls, and solutions for orthotopic bladder substitutions and the patients' quality of life after surgery. When performed properly, orthotopic continent diversion offers good quality of life with few long-term complications. Therefore, we believe it is the best option for the majority of patients requiring cystectomy.

National survey on orthotopic neobladder

OBJECTIVE

A national survey was conducted among the urologists in India to find the preference for urinary diversion after radical cystectomy for muscle invasive carcinoma of the urinary bladder, percentage of neobladder reconstruction, segment of the bowel used, complication rate, need for self-intermittent catherisation on follow up and the survival.

MATERIAL AND METHODS

A detailed questionnaire was mailed to all members of the urological society of India (USI) to find out their preference for urinary diversion following radical cystectomy for muscle invasive carcinoma urinary bladder. For the neobladder reconstruction, they were asked for the type of bowel segment used, complication rate, reoperation rate, need for intermittent clean catheterisation on follow up and 5-year survival.

RESULTS

A total of 24 institutions responded to the mailed questionnaire. Of all institutions 12 (50%) did not prefer the orthotopic neobladder (ONB) reconstruction. Among the institutions carrying out neobladder reconstruction, majority perform ileal conduit in more than 50% of the cases. Ileum (66.66%) or ileocaecal (16.66%) segment was the choice of bowel segment for most of the urologists. Only three institutions used sigmoid colon. The complications encountered were wound infection (5-25%), burst abdomen (5%), urinary fistulas (3-25%), faecal fistulas (2-5%), bladder neck stenosis (5-15%) and ureterointestinal anastomosis stenosis (5-25%). The reoperation rate was 5-15% with a perioperative mortality of 0.5-3%. Around 10-100% (average 50%) of the patients require intermittent clean catherisation. Only seven institutions could provide 5-year survival rate data. Of these three institutions reported more than 50% and four institutes less than 50% 5-year survival.

CONCLUSION

Ileal conduit still remains the urinary diversion of choice following radical cystectomy for muscle invasive carcinoma of the bladder among most of the urologists in India. Orthotopic neobladder reconstruction is practiced only in selected centres. Wound infection, urinary leak and obstruction at ureterointestinal anastomosis are the main complications. Clean intermittent cathaterisation is required at an average of 50% of the patients to ensure complete emptying of the neobladder.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Long-term results of standard procedures in urology: the ileal neobladder

Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2-3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1-2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11-12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.

Contemporary Management of the Urethra in Patients After Radical Cystectomy for Bladder Cancer

The incidence of urethral TCC after radical cystectomy is approximately 8% overall. The most important risk factor for urethral TCC after radical cystectomy and urinary diversion is prostatic involvement by TCC, particularly stromal invasion. The safety of using the urethra for orthotopic urinary diversion seems to be best when intra-operative frozen section analysis of the urethral margin is performed at the time of radical cystectomy. There is provocative but unconfirmed evidence that orthotopic urinary diversion may be protective against the development of urethral TCC. Although most urethral "recurrences" occur within 5 years, delayed recurrences have been documented, mandating life-long follow-up of the retained urethra. Follow-up should include urinary cytology, either voided or urethral wash cytology as appropriate, with evaluation by endoscopy of any urethral related symptoms or change in voiding symptoms. The management of urethral TCC after cystectomy remains a total urethrectomy including excision of the meatus; however, in carefully selected patients with superficial disease and an orthotopic urinary diversion, urethra sparing may be attempted after a careful discussion with the patient. Survival after urethral TCC has generally been disappointing. The relative value of urethral versus original cystectomy pathologic stage and symptomatic versus nonsymptomatic recurrence in predicting survival remains controversial and awaits further studies that will most likely require the pooling of data from several large series.

Orthotopic bladder reconstruction in women--what we have learned over the last decade

Approximately 10 years ago protocols for urethra-sparing cystectomy and orthotopic urinary diversion to the urethra in female patients with bladder cancer were initiated at several centers. Long-term data regarding the oncological and functional outcome are the subject of this review. Studies regarding the relationship between primary bladder cancer and secondary urethral tumors in women revealed in most studies a lower risk for women than for men in most studies. In a recent meta-analysis the incidence of urethral tumors was 6.8% in 5657 male and 3.6% in 841 female patients with transitional cell cancer of the bladder. Anatomical and functional studies revealed that smooth musculature can be found in the entire length of the female urethra. The rhabdosphincter which is the important structure for postoperative continence in low pressure intestinal reservoirs is in the midportion of the urethra which will not be touched during urethra-sparing surgery. A recent study looked at the oncological and functional results of 102 women with orthotopic urinary diversion after a follow-up ranging from one and half to 100 months (mean 26, median 24 months). There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease specific survival of 74% and a disease free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Daytime continence was 82%; nocturnal continence was 72%. Twelve patients (12%) were unable to empty their bladders completely and needed some form of catheterization. Increasing experience in recent years confirms the initial preliminary results showing that sparing the urethra at cystectomy will not compromise oncological outcome and can be satisfactorily used for orthotopic reconstruction of the lower urinary tract. Both diurnal and nocturnal continence and clean intermittent catheterization rates after 6 months justify the use of orthotopic neobladders as the procedure of choice in the majority of female patients with bladder neoplasms.

The lived experience of having a neobladder

The purpose of this phenomenological qualitative study was to describe the lived experience of people who had a neobladder constructed. Men and women with direct and personal knowledge of the experience were interviewed. Analyses of transcribed verbatim narratives were conducted. Major and minor themes with clustered subthemes were identified. Selected themes included diagnosing cancer, detesting the idea of the bag, coping with stressful events, managing tubes and drains, responding to incontinence, keeping the neobladder healthy, and seeing cancer as a lifelong threat.

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

PURPOSE

Orthotopic urinary reconstruction has been shown to be a viable option in women undergoing radical cystectomy. However, due to anatomical differences and technical considerations orthotopic diversion has been performed in a relatively small number of patients. We examined our technique of vaginal wall preservation during female radical cystectomy and orthotopic neobladder construction.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent radical cystectomy between January 1994 and December 2001. Of these 542 patients we identified 94 females, of whom 25 (27%) underwent orthotopic neobladder substitution. We reviewed perioperative major and minor complications, postoperative care, followup and pathological results.

RESULTS

Overall 21 of the 25 patients (84%) underwent anterior vaginal wall sparing. Five patients (24%) had minor complications, there were no major perioperative complications and no patients required transfusion. Median estimated blood loss in this group was 575 ml. (range 200 to 1,250). A single neobladder-vaginal fistula developed in a patient early in our series in whom the anterior vaginal wall was incised and repaired during dissection. Of the 21 patients 15 (72%) were continent. Pathological specimens revealed a negative posterior bladder wall and urethral margins in all cases. At a median followup of 12 months 1 patient had local recurrence.

CONCLUSIONS

Anterior vaginal wall preservation in female radical cystectomy with orthotopic neobladder substitution is technically feasible, maintains vaginal length and support, has an acceptable complication rate and can achieve negative margins. Prospective evaluation is needed to assess the long-term impact on functional outcomes and cancer control.

The remnant urothelium after reconstructive bladder surgery

The pathology of the remnant urinary tract in an increasing population of cystectomy patients with orthotopic and heterotopic bladder substitution due to primary bladder carcinoma, and its management is discussed. The incidence of urethral tumours in primary or recurrent bladder cancer in long-term studies is approximately 6% for male and 2% for female patients. Risk factors for urethral tumour occurrence are tumours at the bladder neck and recurrent multifocal tumours. CIS of the bladder not involving the bladder neck, and muscle invasive tumours with or without lymph node involvement are not significantly correlated with urethral cancer. Those patients at risk for urethral tumours need additional work-up (multiple urethral biopsies and/or urethral brushings, frozen section of the membranous urethra) before an orthotopic lower urinary tract reconstruction to the urethra should be considered. In a large series of male patients, the majority of patients with urethral tumours had a single conservative treatment session, and did not recur thereafter demonstrating the feasibility of a conservative approach for superficial urethral tumour recurrences in patients with an orthotopic neo-bladder to the urethra. The incidence of upper tract tumours following cystectomy and lower urinary tract reconstruction lies between 2.4-17%. In a group of 258 patients with an orthotopic bladder substitution, we have seen an incidence of 3.5%. Tumour multifocality, carcinoma in situ in the bladder and/or distal ureter, locally advanced bladder tumour stage, and invasion of the intramural ureter were seen as risk factors in some series. A tendency for a higher incidence can be seen in those series with longer follow-up. The median time between cystectomy and diagnosis of upper tract tumours lies between 8 and 69 months in most series. A longer observation period in larger numbers of patients with an orthotopic neo-bladder and longer survival rates in general after cystectomy may reveal an increase in the incidence of upper tract tumours over the next decade.

Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors

BACKGROUND

To the authors' knowledge, few data exist regarding the functional and oncologic outcome of pelvic tumors in women with urethra-sparing cystectomy and orthotopic urinary diversion to the urethra.

PATIENTS AND METHODS

The combined data of 102 women age 28-79 (mean, 59 yrs) years who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for either primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient) were reviewed. The histology of the 96 primary bladder tumors was 81 transitional cell carcinomas (TCC), 8 adenocarcinomas, 5 squamous cell carcinomas, 1 small cell carcinoma, and 1 unclassified. Follow-up ranged from 1.5-100 months (mean, 26 mos; median, 24 mos). In all patients, the bladder neck and up to 1 cm in length of the adjacent urethra were removed with the bladder. An ileal orthotopic neobladder procedure was performed if staging biopsies of the bladder neck and intraoperative frozen section of the urethral margin revealed no tumor.

RESULTS

There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease-specific survival of 74% and a disease-free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Three pelvic recurrences occurred, two tumors of the inner genitalia and one adenocarcinoma of the bladder, none of them in the area of the urethra or its supplying autonomic nerves. Daytime continence was 82%; nocturnal continence was 72%. Twelve (12%) patients were unable to empty their bladders completely and needed some form of catheterization.

CONCLUSIONS

The functional and oncologic outcome of female patients with an orthotopic urinary diversion to a remnant urethra was found to be comparable to that found in large studies on males. An orthotopic neobladder proved to be an oncologically safe option for women with pelvic tumors and was found to provide quality of life when there was adherence to previously defined selection criteria.

Preservation of a digital osteotendinous structure with an omental flap

Taking into account the angiogenic properties of the omentum to revascularize ischemic tissues, this experimental, longitudinal, prospective, double-blind study in rabbits was designed to revascularize and preserve the mobility of a digital osteotendinous structure surgically devascularized in advance and to compare such omental angiogenic ability with that of the muscle and the panniculus carnosus. Thirty New Zealand rabbits were used. Three toes from the hind feet were surgically amputated from each rabbit. The skin was removed, exposing the bones, tendons, ligaments, and joints, to form what we termed the osteotendinous structure. Through a median laparotomy, the first part of each rabbit's own osteotendinous structure was placed inside the panniculus carnosus (group I), the second under the rectus abdominis muscle (group II), and the third was wrapped in a pediculate omental flap (group III). Three weeks later, each structure was assessed clinically for mobility and fibrosis and microscopically for fibrosis, newly formed vessels, viability, and tissue regeneration. Clinically, the group I structures showed a greater amount of fibrosis. The structures in groups II and III showed minimal fibrosis in all but four cases, which showed moderate fibrosis. Differences in joint mobility were assessed with the Kruskal-Wallis test. There was a statistically significant difference in mobility for the structures from group III, which was higher, followed by those from groups II and I. The exception was the proximal interphalangeal joints in groups II and III, for which the differences had no statistical significance. Microscopically, fibrosis and tissue necrosis were intense in the structures in group I, moderate in the group II structures, and mild in the group III structures. Conversely, vessel neoformation and tissue regeneration were intense in the structures in group III, moderate in group II, and were nil in group I. This study confirms with statistical significance that, in the rabbit, the omentum has a higher ability to revascularize degloved tissues than do the muscle and the panniculus carnosus, thus preserving a higher joint and tendon mobility. Consequently, it is suggested that a free omental flap be used in the treatment of ring avulsion injuries that lead to degloving of the digits.

Orthotopic ileocolic neobladder reconstruction following radical cystectomy: history, technique and results of the Johns Hopkins experience, 1986-1998

Reconstruction of the lower urinary tract using intestinal segments has become a standard component of the treatment of patients with bladder cancer. A variety of intestinal segments can be successfully used for this purpose. Between 1986 and 1998, the authors have used a composite ileocolic segment for neobladder reconstruction in patients desiring orthotopic reconstruction of the lower urinary tract. The early and late complication rates are 11% and 30%, respectively. Forty-five percent of men are potent postoperatively. Seventy-six percent of patients are continent both day and night. Three percent of our patients experience nocturnal enuresis, and 15% perform clean intermittent catheterization. Bothersome daytime stress urinary incontinence occurs in 3% of patients evaluated for this report. Although no contemporary studies demonstrate the superiority of a particular bowel segment for lower urinary tract reconstruction, the authors' long-term experience with the ileocolic neobladder suggests that this composite segment provides excellent results for lower urinary tract reconstruction after radical cystectomy.

The female urethral sphincter: a morphological and topographical study

PURPOSE

We reassess the anatomy and topography of the female urethral sphincter system and its innervation in regard to urethra sparing anterior exenteration and other surgical procedures.

MATERIALS AND METHODS

Anatomical and histological studies were performed on 9 fetal specimens and 4 adult cadavers. Using graphics software the anatomical structures of the true pelvis were reconstructed based on computerized tomography cross sections and digitized histological sections. On the adult cadavers anterior exenteration was performed to study the implications of the isolated urethra and its sphincter mechanism.

RESULTS

Strata of connective tissue were found to divide the smooth muscles of the proximal two-thirds of the female urethra into 3 layers. Computer guided 3-dimensional reconstruction of digitized histological sections showed that thin fibers of the pelvic plexus course to this part of the urethra. The majority of these fibers may be preserved by carefully dissecting the bladder neck and the proximal portion of the urethra, leaving the lateral vaginal walls intact. The striated rhabdosphincter, which is innervated by fibers of the pudendal nerve, was in the caudal third of the urethra.

CONCLUSIONS

A well-defined sphincteric structure or sphincter could not be anatomically recognized in the bladder neck region. The majority of rhabdosphincter fibers were found in the middle and caudal thirds of the urethra. Thus, in patients undergoing removal of the bladder neck and part of the proximal portion of the urethra continence can be maintained by the remaining urethral sphincter system, provided that innervation remains essentially intact.

Mechanisms of incontinence and retention after orthotopic neobladder diversion

OBJECTIVES

To define the mechanism of incontinence and retention after orthotopic neobladder diversion.

METHODS

The results of urodynamic and endoscopic evaluations were assessed in 19 patients (15 men and 4 women). Mean age and postoperative follow-up were 58.3 years and 19.6 months, respectively. Seventeen patients (15 men, 2 women) presented with the sole complaint of nocturnal incontinence, and 2 women presented with retention. Evaluations included voiding and continence history, pelvic examination (for women), postvoid residual, uroflowmetry, triple-lumen video-urodynamic study, and cystourethroscopy.

RESULTS

Among patients with incontinence, 11 (65%) were found to have a primary failure-to-store problem as a result of either reservoir or sphincter failure. Four patients (24%) had a primary failure-to-empty problem, and 2 (11%) had features of both. The predominant etiology of voiding difficulty was the inability to relax the external urethral sphincter adequately during Valsalva's maneuver. Of the 2 women who presented with retention, one had obstructing mucosal folds at the neobladder opening and both demonstrated anterior vaginal wall prolapse on pelvic examination.

CONCLUSIONS

The mechanism of incontinence and retention after orthotopic neobladder diversion can vary. Carefully performed urodynamic and endoscopic assessments can define the underlying etiology and may serve as a guide for proper treatment selection.

Historical perspective of the use of bowel in urology

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.

Update of urethra-sparing approaches in cystectomy in women

The emerging experience in urethra-sparing cystectomy in women undergoing subsequent orthotopic lower-urinary-tract reconstruction with regard to the anatomy of the remnant urethra, patient selection, refinements of the surgical technique, the patients' outcome with respect to the underlying disease, the risk for tumor recurrence, and postoperative urodynamics are the main focus of this report. In the present study, 30 carefully selected female patients underwent orthotopic reconstruction of the lower urinary tract. Surgical variations emerging from the first learning curve, including nerve-sparing anterior exenteration, vaginal reconstruction, omental support of the neobladder floor, and ureterointestinal anastomosis, were applied in 21 patients with lower-urinary-tract reconstruction. Of 24 patients followed for more than 6 months, 21 (87.5%) are continent at daytime, 19 (79%) have nocturnal continence, and only 1 (4%) requires self-catheterization; 3 patients with urinary retention were successfully treated for obstructed ileal valves. After a follow-up period of 2-41 (mean 15.4) months one patient each developed local recurrence (uterine adenosarcoma) after 13 months and distant metastasis transitional-cell cancer of the bladder after 3 months; all other patients are currently free of disease. Urethra-sparing surgery has established itself in selected women with bladder cancer. Refinements in the technique of radical cystectomy and orthotopic creation of a neobladder to the urethra may improve the continence, spontaneous micturition, and surgical oncological outcome of these patients.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.