Full text of DOI:10.1016/S0022-5347(05)67651-3

0022-5347/00/1635-1501/0
®
THE JOURNAL OF UROLOGY
Vol. 163, 1501–1504, May 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Printed in U.S.A.
Female Urology
FEMALE ORTHOTOPIC BLADDER SUBSTITUTION: A GOOD
OPERATION IN THE RIGHT CIRCUMSTANCES
ROBERT D. MILLS AND URS E. STUDER
From the University Departments of Urology, Addenbrooke’s Hospital, Cambridge, England, and Anna Seiler-Haus Inselspital, Berne,
Switzerland
ABSTRACT
Purpose: We present the long-term results of orthotopic bladder substitution in women.
Materials and Methods: We prospectively assessed 15 female patients undergoing orthotopic
bladder substitution between October 1984 and April 1998. The indication for diversion was
bladder carcinoma in 8 cases, gynecologic malignancy in 2 and benign disease in 5.
Results: At a median followup of 19 months daytime and nighttime continence was 100% and
80%, respectively. All but 1 patient voided spontaneously. Two patients who were initially able
to void successfully had voiding difficulties in the initial 10 months due to prominent mucosal
tissue at the bladder neck. In each case this condition was successfully managed by endoscopic
resection. There has been no local recurrence of bladder carcinoma.
Conclusions: With strict selection criteria and vigilant followup female orthotopic bladder
substitution produces excellent long-term functional results comparable to those in men. How-
ever, the limits in women who require radical cystectomy for invasive bladder cancer cannot be
determined from our results. Further long-term data on the local recurrence rate of invasive
urothelial malignancy are needed before the true risk may be quantified accurately.
KEY WORDS: bladder; cystectomy; urinary diversion; surgical procedure, reconstructive
Orthotopic bladder reconstruction is widely performed in
men. Approximately 50% of male patients who undergo cys-
tectomy for invasive bladder cancer are suitable candidates
for this type of surgery. Female orthotopic reconstruction has
been much less widely practiced, mainly due to anatomy as
well as the perceived increased risk of local recurrence and
voiding dysfunction after urethral sparing surgery. As a re-
sult of detailed histological evaluations of cystourethrectomy
specimens from women with bladder cancer1–3 and a more
comprehensive understanding of the female continence
mechanism,4–6 female orthotopic reconstruction is now be-
coming more widely practiced. However, published results
are still sparse with limited followup. The largest series to
date includes 34 patients.7 We report our results in a group
of highly select, consecutive women who underwent ortho-
topic reconstruction during the last 15 years.
Preoperative diagnosis in 15 women who underwent orthotopic
reconstruction
Diagnosis
No. Pts.
8
5
3
3
2
2
Transitional bladder Ca:
Multifocal grade 3 stage pT1
Invasive
Adenoca.
Gynecologic malignancy (recurrent cervical Ca
after radiotherapy)
Benign disease:
5
1
2
Small bladder capacity after tuberculosis
Small capacity bladder with vesicovaginal (1)
or vesicointestinal (1) fistula after radio-
therapy for cervical Ca
Neuropathic bladder
Interstitial cystitis
1
1
METHODS
The 5 patients with benign disease underwent simple cys-
tectomy without opening the vagina and the 3 with superfi-
cial bladder cancer underwent limited lymphadenectomy.
The uterus and vagina were preserved in 2 cases. In the
remaining woman who previously underwent hysterectomy
the vaginal stump was not disturbed. Bilateral nerve sparing
was attempted in each case.
The 5 patients with invasive bladder cancer underwent
radical cystectomy with complete pelvic lymphadenectomy.
Preservation of the uterus and vagina was possible in 1 case
of adenocarcinoma in the bladder dome and anterior wall.
Hysterectomy was performed with excision of the anterior
vaginal wall en bloc with the specimen in 3 cases. In the
remaining patient who previously underwent hysterectomy
for benign disease the anterior vaginal wall only was excised
with the specimen. Although resection of the anterior vaginal
Between October 1984 and April 1998, 15 female patients
underwent orthotopic ileal bladder reconstruction with an
isoperistaltic tubular afferent limb. The indication for sur-
gery was bladder carcinoma in 8 cases, gynecologic malig-
nancy in 2 and benign disease in 5 (see table). In the 5 women
with invasive bladder cancer pathological stage was pT3aN0
(2), pT3bN0 (2) and pT3bN1 (1), according to 1992 Interna-
tional Union Against Cancer terminology. Preoperative as-
sessment of bladder cancer involved cystoscopy, physical ex-
amination using anesthesia, and full thickness bladder
biopsy from the bladder neck and trigone to exclude overt
tumor and carcinoma in situ from a zone of at least 1 cm.
around the bladder neck.
Accepted for publication November 5, 1999.
1501

1502
FEMALE ORTHOTOPIC BLADDER SUBSTITUTION
wall was necessary in 4 of these 5 patients, the vaginal wall anterior pouch wall was fixed to the posterior aspect of the
was incised only after the lateral paravaginal tissues were symphysis to prevent collapse of the reservoir wall onto the
clearly identified, mobilized, severed and ligated. This dis- urethral outlet. Total anterior pelvic exenteration was done
section immediately along the whitish vaginal wall was fa- with simultaneous creation of an ileal neovagina from the
cilitated by an empty sponge holding forceps in the vagina. most distal part of the resected ileal segment in the 2 pa-
To remove lymphatic glands draining the bladder base on the tients with recurrent cervical carcinoma.
tumor bearing side the paravaginal tissue was widely excised
Postoperative management, which was the same as in our
as far as the pararectal region. In contrast, dissection on the male patients, has also been described previously.9 We re-
opposite side proceeded no further than the 2 or 10 o’clock moved the ureteral stent between days 5 and 7, and the
position, dividing the autonomic nerve supply from the pelvic cystostomy tube after radiography of the pouch on day 10
plexus passing to the bladder while attempting to preserve postoperatively. On day 12 the urethral catheter was re-
the paravaginal fibers passing more dorsally to the urethra moved and patients were taught to void by pelvic floor relax-
(fig. 1). On each side paravaginal dissection did not proceed ation without abdominal straining. Initially they were asked
beyond the bladder neck. Anterior dissection remained as to void at 2 and 3-hour intervals during the day and night,
close to the bladder as possible to limit damage to the ure- respectively, even if this resulted in incontinence. With time
thropelvic ligaments and urethral innervation at this level. and in the absence of complications the voiding interval was
To minimize damage to the intrapelvic somatic fibers from gradually increased. This process is essential to increase
the pudendal nerve, which also contribute to urethral inner- reservoir capacity, which is approximately 120 ml. during
vation,6 the endopelvic fascia overlying the pelvic floor was convalescence. Post-void residual urine was excluded by
disturbed as little as possible in all patients. The urethral daily ultrasound. Regular blood gas analysis was done and
resection line was just distal to the bladder neck in those acidosis was treated with sodium bicarbonate as necessary.
with malignant disease and the woman with interstitial cys-
Functional results were recorded prospectively as part of
titis. In the remaining 4 patients who underwent surgery at our standard protocol of interviews, a validated question-
the beginning of our series a 1 to 10 mm. cuff of bladder neck naire, frequency volume charts and post-void residual urine
was preserved.
volume assessment. Patients were regarded as continent
Creation of the reservoir, which is not particular to women, while no more than a few drops of urine were lost once or
has been described previously.8 However, we emphasize that twice weekly. Regular urethral washout cytology was per-
the anastomosis was not fashioned at the funnel shaped formed in those with bladder cancer using a short stiff cath-
lower end of the anterior suture line, which is the most eter with multiple side holes, a syringe and 60 ml. of saline.
dependent part of the pouch, but offset 3 to 4 cm. from this The catheter was advanced and withdrawn in the urethra to
point. In some cases after completing the anastomosis the collect the washout from the meatus in a kidney dish. We
have not routinely obtained voided specimens. Vaginal exam-
ination was done in all patients with a history of pelvic
malignancy.
RESULTS
Median patient age at surgery was 56 years (range 27 to
75) and median followup was 19 months (range 6 to 153). Of
the 15 women 13 were alive at the last followup. One of the
2 patients with cervical carcinoma had local recurrence
and each died of widespread metastatic disease at 7 and 19
months, respectively. Pelvic recurrence developed at
33 months in another woman with a fistula after radiother-
apy for cervical carcinoma 4 years previously but no evidence
of recurrent disease at surgery. The orthotopic reservoir was
excised with the anterior vaginal wall and an ileal conduit
was constructed.
None of the 8 patients with bladder cancer had evidence of
local recurrence. However, the woman with node positive
disease had lung metastasis and another in whom disease
was pathological stage T1 at cystectomy had bone and liver
metastases at 14 months. Postoperative obstructive renal
impairment in 2 cases was due to recurrent cervical cancer in
1. The other patient had a ureteroileal stricture in a single
functioning renal unit as well as a rectovaginal fistula at 4
and 6 months, respectively. She had received 60 Gy. of ex-
ternal beam radiotherapy for cervical carcinoma 5 years ear-
lier. Treatment involved ureteral reimplantation and end
colostomy with preservation of the orthotopic reservoir.
Daytime continence rates were 79%, 83% and 100% at 6, 12
and 24 months of followup, respectively. These rates include
2 patients who were fully continent at 6 months and 1 at 12
and 24 months each who had occasional loss of a few drops of
urine no more than once or twice weekly. Nighttime conti-
nence rates were 71%, 83% and 89% at 6, 12 and 24 months
of followup (fig. 2). There was a mean of 6 (range 4 to 8) and
2 (range 1 to 4) voids during the day and night, respectively,
FIG. 1. Proposed nerve sparing dissection. Paravaginal dissection
at 6, 12 and 24 months.
extends as far back as pararectal region on tumor bearing left side
(a). In contrast, on nontumor bearing side dissection remains closer
to bladder base at anterolateral vaginal aspect (b).
At the last followup median bladder capacity was 475 ml.
(range 250 to 850) and median post-void residual urine vol-

FEMALE ORTHOTOPIC BLADDER SUBSTITUTION
1503
topic reconstruction if local recurrence is to be avoided. There is
no anatomical barrier, such as Denonvilliers’ fascia, between
the bladder base and anterior vaginal wall. Therefore, we ex-
cise the anterior vaginal wall with the specimen when invasive
tumor is present in the bladder base or encroaches on the
trigone. Lymphatic drainage from the bladder base and trigone
occurs along the lateral vaginal wall to nodes along the hypo-
gastric artery. This tissue should also be removed on the tumor
bearing side. Stein et al indicated that transitional carcinoma at
the bladder neck need not necessarily be a contraindication to
orthotopic diversion if, as in 50% of these patients, the urethra
is free of tumor.7 We think that the risk of persistent disease is
too high, particularly since radical surgery with a safe margin
still provides the best chance for cure in these cases. Stein et al
recommended intraoperative frozen section at the urethral re-
section margin as the best method for determining patient
suitability for orthotopic reconstruction and they relied on this
technique only. We believe that preoperative assessment is
preferable because the quality of permanent paraffin embedded
sections is superior, particularly since small tumor clusters and
mucosal atypia may be missed by frozen section. Furthermore,
it seems preferable to excise the area of the bladder neck,
proximal urethra and surrounding tissue en bloc at a safe
distance from a diseased bladder neck rather than discover that
this area is involved with tumor only after incising it for frozen
section analysis at surgery. We also think that it is desirable to
provide patients with the best possible information on the types
of urinary diversion available before surgery. Longer followup
of a larger number of patients is required than currently avail-
able in the world literature before the true risk of local recur-
rence may be quantified accurately.
FIG. 2. Patients who achieved daytime and nighttime continence
during initial 24 months.
ume was 5 ml. (range 0 to 400). Of the 15 patients 13 voided
with a post-void residual urine volume of less than 50 ml.
One patient voided with a post-void residual volume of 150
ml. at a followup of 8 years. A woman who was congenitally
blind, diabetic and wheelchair bound did not void postoper-
atively and underwent urethral catheter placement at 12
months, explaining the high end of the post-void residual
volume range in our study.
Two patients with a distal resection margin below the
bladder neck who initially voided without significant post-
void residual urine (less than 50 ml.) had chronic urinary
retention at 4 and 10 months, respectively. Endoscopic as-
sessment revealed prominent mucosal tissue just above the
anastomosis in each case. The tissue was resected at 1 oper-
ation in 1 patient and at 2 in the other, after which each
again voided to completion.
The reported functional outcome differs among series, par-
ticularly in regard to voiding ability. Some reported a 53%11
and 41%12 rate of intermittent catheterization, whereas oth-
ers noted a much lower rate of 0%13 and 3%.14 Our functional
results with excellent daytime and nighttime continence,
good bladder capacity, 93% of patients voiding without cath-
DISCUSSION
The aim of orthotopic bladder reconstruction is to provide a eterization and acceptable voiding frequency are as good as
compliant, low pressure continent urinary reservoir that may our results in men. These results reflect the highly select
be emptied completely at socially convenient intervals. It is nature of our patient group with no evidence of gross sphinc-
now accepted that the female urethra may be preserved in ter dysfunction. However, operative technique and followup
cases of invasive bladder cancer that do not involve the are equally important.
trigone and the female continence mechanism may function
Intraoperatively we believe that nerve sparing is impor-
adequately after cystectomy. Although it is not ideal, we tant to optimize continence and voiding ability. The extrapel-
believe that when patients are suitable candidates, ortho- vic pudendal nerve to the external striated sphincter is not at
topic reconstruction is currently the best type of urinary risk but the intrapelvic extra pudendal somatic supply from
diversion available.
the second and third sacral roots may easily be damaged as
The indications for female orthotopic reconstruction in- well as the autonomic branches of the pelvic plexus. To our
clude invasive bladder carcinoma, superficial bladder carci- knowledge the absolute contribution to sphincter function of
noma resistant to conservative measures, other pelvic malig- these latter 2 sources is not clear. However, in canine exper-
nancies requiring exenteration and benign conditions iments Hubner et al demonstrated a pressure increase in the
resulting in a small shrunken bladder or intractable irrita- distal urethra after pudendal nerve stimulation and in the
tive symptoms with preserved sphincter function. When per- proximal urethra after stimulation of the pelvic plexus.15
formed for malignant disease, the desire to achieve a func-
We emphasize that one may never be certain whether
tionally good result should not compromise surgical nerve sparing has been achieved. A successful outcome may
resection. The primary concern in invasive bladder carci- also be due to careful operative technique that avoids direct
noma should be tumor clearance by cystectomy. Cordonnier injury to the sphincter mechanism. Stein et al7 and Ghoneim13
and Spjut reported local urethral recurrence after incomplete think that nerve sparing is not important and justify this
urethrectomy during cystectomy for bladder cancer10 but we approach by their results. They believe that continence is
are not aware of any urethral recurrences after female ortho- provided by the resting tone of the striated muscle compo-
topic reconstruction for bladder cancer. Only 5 of our female nent supplied by the pudendal nerve, the elastic fibers of the
patients had invasive bladder cancer, whereas a further 90 urethral wall and mucosal apposition. We agree that nerve
during the same period underwent cystectomy for invasive sparing should not compromise the radical nature of the
bladder cancer at our department. Our approach undoubt- operation but we also believe that autonomic innervation has
edly changed during the study period and we would probably functional significance. Without nerve sparing patients may
now offer orthotopic reconstruction to some patients who be continent most of the time but have leakage during stress
previously underwent diversion by alternative means. How- due to shortened functional urethral length. Conversely, just
ever, it is not uncommon for the primary tumor to involve the as a preserved but dysfunctional bladder neck may theoret-
trigone. Coloby et al reported a 44% incidence in 43 cystec- ically result in obstructed voiding, a denervated floppy prox-
tomy specimens in patients with transitional cell carcinoma.1 imal urethra may lead to ineffective active relaxation or
Care must be taken when assessing these patients for ortho- simply kinking during voiding and, thus, incomplete empty-

1504
FEMALE ORTHOTOPIC BLADDER SUBSTITUTION
ing. Nerve sparing may in fact be more important in women perienced in pelvic surgery, meticulous operative technique
since there is a substantial smooth muscle component in the and vigilant followup. It is imperative that the radical nature
female urethra compared to the male membranous ure- of cancer surgery not be compromised by the desire for re-
thra.16
construction if local recurrence of bladder carcinoma is to be
Sensory innervation of the urethra from the intrapelvic avoided.
branches of the pudendal nerve or branches of the pelvic
plexus may also have a role in preventing urinary leakage.
Division of these nerves may result in loss of the afferent
limb of an external sphincter guarding reflex stimulated by
urinary leakage into the proximal urethra.17 To our knowl-
edge the effect of attempted nerve sparing on sexual function
is unknown to date but it requires further investigation.
Other important technical considerations include preser-
vation of the urethral support mechanism, optimal reser-
voir capacity and anastomotic site. We aim for an initial
bladder capacity of approximately 100 to 200 ml., which
increases to 400 to 500 ml. in the first 12 months postoper-
atively. Daytime frequency, nocturia and leakage are greater
when final capacity is less than 300 ml. However, large
floppy bags are undesirable because they have lower reser-
voir pressure for a given radius and, therefore, empty less
well. Anastomotic site away from the most dependent part of
the reservoir provides a broad contact of reservoir wall with
the pelvic floor, which avoids a narrow funnel shaped outlet
that would kink during voiding, leading to obstruction.
In the postoperative period voiding re-education is of par-
amount importance. Patients must clearly understand the
principle that lowering outlet resistance is the key to success.
Increasing intra-abdominal pressure only does not allow
voiding. Instruction on pelvic floor relaxation, regular void-
ing to prevent over distention and regular followup are es-
sential.18 A dedicated liaison nurse whom patients may con-
tact directly is invaluable. Complications in our series
confirm the higher risk of surgery after radiotherapy. The
patient who had a stricture at the ureteroileal anastomosis
and a rectovaginal fistula previously underwent 60 Gy. ex-
ternal beam radiotherapy. Our patient who was blind, dia-
betic, wheelchair bound and unable to void was not a suitable
candidate for any type of urinary diversion. Although this
situation was clearly not ideal, to date she and her caregivers
have managed the urethral catheter by intermittent spiggot-
ing and regular washouts, preventing catheter blockage and
symptomatic infection of urine.
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An interesting complication in 2 cases was chronic reten-
tion during year 1 despite initial good voiding. These women
were successfully treated with the resection of prominent
mucosal tissue at the bladder neck. This problem, which we
have not encountered frequently in male patients, may be
due to a relative lack of support in the more capacious female
pelvis, predisposing to collapse of the reservoir wall toward
the outlet. Therefore, in some patients we now fix the ante-
rior wall of the reservoir to the anterior pelvic wall, main-
taining its position as the reservoir empties. Further fol-
lowup is required to determine whether this technique
proves beneficial.
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lowing cystectomy for bladder cancer. Urol Clin North Am, 24:
225, 1997
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CONCLUSIONS
A successful functional outcome comparable to that in men
may be achieved after female orthotopic bladder substitution.
To date our patients have been highly select, although the
number undergoing this form of surgery is likely to increase.
To maintain good long-term results certain elements are
essential, including careful patient selection, a surgeon ex-