Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results

Abstract

Purpose: Analyze current knowledge and practice regarding tumor-related cystectomy with subsequent orthotopic neobladder both in male and female patients. Design, setting, and participants: Evaluate literature predominantly from the last decade dealing with long-term experience in large numbers of patients with an orthotopic neobladder following cystectomy. Oncological outcome specific to an orthotopic neobladder, functional aspects such as urinary continence, renal function, sexual activity and other quality of life issues are elucidated. Results: Local pelvic recurrences after urothelial bladder cancer occur in 7-12%. Urethral second primary tumors in male and female patients in contemporary series with bladder substitution are 4-6% and 1.4 o 4%, respectively. Upper tract recurrences vary between 2.4-17%. Complications regarding the upper urinary tract have dramatically diminished due to simplified forms of upper tract protection as well as a more refined technique of ureterointestinal anastomosis. Depending on the technique ureteroileal stenosis was lately reported to lie between 2.7 to 3.8%. Renal function remained stable in 96% after a mean follow-up of up to 5 years. Conclusion: Radical cystectomy in carefully selected patients has stood the test of time by providing adequate long-term survival and low local recurrence rates. Orthotopic bladder substitution does not compromise oncological outcome, yields excellent functional results, is cost effective compared to other types of urinary diversion, may improve quality of life and should therefore be the diversion of choice both in men and women. Chronological age is generally not a contraindication for cystectomy, but for orthotopic urinary diversion, tumor extent, functional pelvic floor deficits and general life expectancy are limiting factors.

Ureterocutaneostomy: for whom and when?

“…[8] Some relative contraindications related to orthotopic reconstruction of neobladder exist which may include delivery of higher doses of preoperative RT; complex urethral stenosis, extremely severe urinary incontinence secondary to urethral sphincter insufficiency (LE:2b). [15][16][17][18] In our clinic, the most frequently used types of UD are priorly ureterocutaneostomy, followed by predominantly Studer type orthotopic neobladder procedures, and finally UCN. When 27 cases of UCN performed within an indicated period were generally reviewed, it appears that this method had been resorted to, because of locally advanced disease, intestinal, and general health problems which might affect intraoperative survival, and induce risks of serious complications.…”

The Health Economics of Bladder Cancer: An Updated Review of the Published Literature

“…Additional data on the quality of life associated with different reconstructive surgeries would be useful to facilitate economic comparisons. A previous review of the literature suggested that orthotopic neobladder substitution was cost effective [88]. However, a consensus has not been reached on the effect of continent diversion on utility in quantitative studies [89], despite the presumption that preserving normal urination prevents deterioration in quality of life.…”

Postoperative Quality of Life in Patients with Ileal Neobladder at Short-, Intermediate- and Long-Term Follow-Up

“…There are different types of diversion that include the realization of an orthotopic neobladder or the creation of an ileal conduit as mainly relevant alternatives. Different types of urinary diversion have different kinds of impact on the patient quality of life (QoL) concerning micturition, physical, sexual and psychosomatic functions, influence on daily activities and psychological consequences related to body image [2,3]. Today the type of urinary diversion accepted as main choice by the urological community seems to be the realization of an orthotopic continent reservoir instead of the ileal conduit, even if this choice is not fully validated by some of the most recent studies about QoL [3].…”