English articles

Orthotopic neo – bladder in women

 

Radical cystectomy is the most effective treatment madality for the urinary bladder carcinoma. Orthotopic reconstruction has been the favored method in the male patient; the improved knowlwdge of the urethral anatomy and some new upgrades in surgical reconstructive technique have afforded the option of the orthotopic reconstruction of the urinary tract in the female too. (1) Because of these advances adequate reconstruction can follow radical surgery and at the same time allow an excellent recovery of bladder function.

     MATERIAL AND METHODS

     From 2002 to 2007  we  have done 14 radical cystectomies followed by orthotopic reconstruction in women aged between 47 and 68 (Mean age 56). All of the patients were affected by urinary bladder carcinoma. In all of the case the diagnosis  had been established with a TURb: 8 had undergone  cycles of intravescical immunotherapy with BCG prior to surgery. All the patients were studied with  abdominal and pelvic ct scan and with a bone scan. No one was found to have pathological enlarged lynphonodes, no bone metasthasis or involvment of the organs were found. In addition  in one patient who  had been treated with BCG  the bladder lining was found negative with 2 biopsies done 2 months apart. One patient had been treated with radical hysterectomy for ca of the portio 25 years before.

     Our technique requires the preparation of 2 strips of the recti muscles fascia: these pedicles arise distally to the pyramidal muscles and will come in handy at the end of the procedure to fashion a sling to be placed under the urethra. The sectioning of the bladder neck is obtained via the cleavage plane between the urethra and the vagina which allows the suspension of the cervical region and affords the sectioning of the urethra very proximally to the bladder neck. When the uterus is present we perform the hystero-annex-cystecomy en block leaving intact the lateral and inferior vaginal walls. After closing the vaginal stump the pelvic floor is stabilized by performing a colposacropexis with a prosthesis (2) (foto 1 ,2) and placing an omental flap over the prosthesis (foto 3). The orthotopic reconstruction is achieved via a neobladder obtained from the detubularized ileum  reshaped according to the  Padovana techinique (3) using 45 cm of the terminal ileum (foto 4).  The ureters are anastomized to the neobladder and splinted with a “mono pg-tail” stent. The new reservoir thus created is ansthomosed to the urethral stump and placed over the pevic omentoplasty wich is suspended over the prolene prosthesis of the colposacropexis.

      RESULTS

     The pathological staging has proven il all of the patients the presence of a high grade carcinoma (G3): more specifically 4 patients had a full thikness intramural infiltration (T2), 2 patients had involvment of the perivescical fat (T3) ad 8 patients were T1. All of the lymphoadenectomies performed during these procedures were negative (N0); no lymphonodal dissection was performed in the patient who had been treated with radical hysterectomy (Nx). In 8 patients blood trasfusion were necessary to treat post surgical anemia. All patients received antibiotic profilaxis for 10 days using cephalosporins and also anticoagulant therapy was administered with local molecular weight heparin for 20 days.

     The ng tube was left in for an average 5 days. The ureteral catheters were left in for an average 12 days (10-16); the cv has been removed in all on the 21st post op day. The abdominal  peristalsis resumed promptly in all patients and the normal bowel evacuation resumed after 4 to 8 days. No significant intra, peri or post operative complications were noted.

     The mean follow-up has been 45 months: there has been 1 death from diffuse metastatic disease after 11 months. The remaining patients are alive and report normal  lifestyle: 10 report normal micturition and 4 have urinary ritention  treated whit self intermittent cateterization. 2 patient report nocturnal incontinence treated with hourly micturition and 1 pad. The five patients who had normal preoperative sexual intercourse have resumed a normal sexual activity.

     DISCUSSION

     The possibility to recontruct the female urinary bladder orthotopically has become established long after the same had been done for males. This is in part due to the relatively smaller number of cases of severe patology in women, in part to the less perfect knowledge of the anatomy of the female urethra. Subsequently , as the procedure begun establishing itself, it became obvious that it needed to be done in conjunction with the recostruction of the pelvic floor, in order to assure a satisfactory function af the new bladder. Of fundamental importance for the aquisition of knowlwdge of the anatomy and physiology of the baldder were the works of Colleselli & Bartsch (1 ,4) in the mid 90’s: they researched this problem clarifying that radical surgery could be done while sparing the urethra and preserving continence. These authors established that on one hand the recurrence of urothelial ca in the urethra is rare occurence (5)  , on the other the bladder neck and the proximal third of the urethra could be removed without damaging the sphincter action (1,4,6 ).

     Of great importance as well was the discovery of the innervation of the urethra running in the lateral vaginal walls: Stenzl and Hautmann (4,6) teorized  that these walls need to be spared in order to denervate the urethra and compromise continence. In particular we have established that the vagina constitutes the fulcrum of the new pelvic arrangement. Stenzl  anchor the newbladder to the pelvis in order to avoid the posterior prolapse (4): our technique vails itself of this improved knowledge.

     The anatomical sparing of the urethra is easily obtained due to the wider lay out of the female pelvis and we routinely spare the lateral vaginal walls to allow for the preservation of the urethral innervation.

     Gaining from  our personal experience we have midified the technique to avoid a posterior slippage of the vaginal stump descrbed by Timmons & Addison (2,7): our method affords  the possibility of a good pelvic stabilization by inserting the vaginal stump into a prolene tube wich is then anchored posteriorly to the sacral periostium. The implant of prosthetic material into the pelvic area could stimulate adhesions or erosion into the new bladder: in order to avoid this we cover the prolene with a  flap of omentum pedicled down from the transverse colon and brought into the pelvis through the right colic space. The new field is solid and stable and is well protected thus able to accept the new bladder. The adoption of a cover made by the omentum also serves well the purpose to avoid another possible important complication: the formation of a fistula between the vagina and the newbladder (8).

     We use the Padovana technique (3) to better allow the hook up of the bladder neck to the urethra avoiding extreme traction on the  new loop. This new reservoir, like all the intrabdominal ones, empties in response to an increase of the intrabdominal pressure that needs to act upon a stable base (9). In 4 patients we have urinary retention due to excessive urethral correctin or to a “floppy bag”. Another matter off discussion is the stress incontinance in patients affected by this problem before surgery: in these patients we have fashioned a sub urethral sling using the recti muscles fascia pedicled on the pyramidal muscles. In other cases the correction of the problem can be obtained after with an eterolougous sling or urethral bulking. With this type of reconstruction one can respect the female pelvic anatomy as it can be attested by preserved and regained sexual activity.

The “Tube “ shaped prosthesis for the colposacropexy

The “Tube “ shaped prosthesis for the colposacropexy

 The vaginal stump is inserted into a prolene prosthesis

The vaginal stump is inserted into a prolene prosthesis

The omental flap peduncolized from the trnsverse colon

The omental flap peduncolized from the trnsverse colon

The final reconstruction of the vescica ileale padovana

The final reconstruction of the vescica ileale padovana

 

 

REFERENCES

1. Colleselli K.; Stenzl A. ; Eder R. ; Strasser H. ; Poisel S. ; Bartsch G.
The female urethral sphincter : a morphological and topographical study.
J.Urol ., 160: 49 – 54                                1998
2. Schettini M. : Fortunato P. ; Gallucci  M.
Abdominal sacral colpopexy with prolene mesh
Int Urogynecol J. , 10 : 295 – 299             1999
3. Pagano F. ; Artibani W. ; Ligato P. ; Piazza R. ; Garbeglio A. ; Passerini G.
Vescica ileale padovana : a technique for total bladder replacement.
Eur. Urol.   17(2) : 149 – 154                     1990
4. Stenzl A. ; Colleselli K . ; Poisel S. ; Feichtinger H. ; Pontasch H. ; Bartsch G.
Rationale and technique of nerve sparing radical cystectomy before an orthotopic neobladder procedure in women.
J. Urol. , 154 : 2044 – 2049                       1995

5. Stenzl A. ; Draxl H. ; Posch B. ; Colleselli K. ; Falk M. ; Bartsch G.
The risk of urethral tumors in female bladder cancer: can the uretra be used for orthotopic reconstruction of the lower urinary tract?
J. Urol. , part 2  153 :  950                         1995

6. Hautman R.E. ; Paiss T. ; De Petriconi R.
The ileal neobladder in women : 9 years of experience with 18 patients.
J. Urol.,  155 : 76 – 81                                1996
7. Addison W.A. ; Timmons M.C.
Abdominal sacral colpopexy for the treatment of vaginal vault prolapse with enterocele.
In: Rock J.A. Thompson J.D. eds. Te Linde’s operative gynecology, 80th edn Philadelphia : Lippincott-Raven   :   1030 – 1037    1997
8. Smith J A. Jr
Neobladder-vaginal fistula after cystectomy and orthotopic neobladder costruction.
J. Urol. 174 : 970 – 971                            2005
9. Gotoh M. ; Mizutami K. ; Furukawa T. ; Kinukawa T. ; Ono Y. ; Osshima S.
Quality of micturition in male patients with orthotopic neobladder raplacement.
World J Urol   18 : 411 – 416                    2000
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