Introduction

Radical cystectomy with orthotopic neobladder has become an established treatment for muscle-invasive bladder cancer in females [1]. There is a Considerable interest to preserve the gynecologic tract during cystectomy without affecting the oncologic outcome to maintain the sexual function [2]. Young females with bladder cancer have a desire to preserve the uterus and adnexa for retaining the reproductive function [3]. The oncologic principle of routine removal of the internal genital organs during cystectomy has been questioned. Groutz et al. found only one patient with uterine involvement in examined cystectomy specimens of 37 patients with bladder transitional cell carcinoma [4]. The pathological revision of the resected internal genital organs after anterior pelvic exenteration has revealed that it could be preserved, so the patients might be spared from adverse effects such as acute early menopause, infertility and cessation of the sexual life [5]. More recently, Ali-El-Dein et al. concluded that Genital sparing cystectomy for bladder cancer in selected female patients is feasible; it provides a good functional outcome, better sexual life and a potential for fertility preservation without affecting, the oncologic outcome after a long follow up [6].

Patients and Methods

Our local institutional review board approved this study according to Declaration of Helsinki. Among 160 patients who underwent radical cystectomy at our oncology center for muscle invasive carcinoma of the bladder between January 2007 to May 2014 (90 male and 70 female), a 24 females underwent gynecologic tract sparing cystectomy (GTSC) while the other 46 had an anterior pelvic exenteration. An informed written consent was obtained from all patients. We started the (GTSC) at 2010. Age ranged from 45 to 60 years with a mean age 51 years.

Inclusion Criteria

All patients were T2bN0M0 or less. All patients had a biopsy proven muscle-invasive disease with no evidence of extravesical spread on clinical evaluation and imaging studies including triphasic computed tomography.

Exclusion Criteria

Patients with diffuse carcinoma-in-situ, those with proven extravesical spread or those with tumors involving the bladder neck were excluded. Other exclusion criteria included patients who were preoperatively incontinent or those with poor general condition.

Pre- Operative Preparation

Pre-operative history was taken from all patients including the gynecologic history. Pre-operative clinical examination included general, abdominal, chest, cardiac examination. A thorough pre-operative gynecological assessment was done in all patients. Laboratory investigations were done for patients' fitness. All patients had a serum creatinine of less than 1.8 mg %. Radiological assessment was done with contrast pelvi-abdominal C.T and metastatic work up in the routine way. Finally cystoscopic examination and biopsy were done.

Surgical Procedure (Figs. 1 and 2)

Our technique of gynecologic-tract sparing cystectomy (GTSC) with neo-bladder was based on our experience gained in the performance of radical cystectomy and anterior pelvic exenteration in female patients. Bowel preparation was started at the morning the day before operation. A site for a stoma was marked if it was necessary to create a conduit. The patient was placed in the supine position. An eighteen Folly’s catheter was passed and the balloon was inflated to 20 cm3. A betadine soaked pack was inserted in the vagina. The abdomen was explored through an infra-umbilical midline incision and the transversalis fascia was incised. Bilateral pelvic lymphadenectomy was performed from the common iliac artery bifurcation along the external iliac artery and vein to the femoral canal distally and obturator nerve medially. Then dissection was carried out along the internal iliac artery. The uterine artery was spared with bilateral ligation of the superior vesical artery. The utero vesical peritoneal attachment was divided. The retro pubic space was dissected till the lateral vesical ligaments were divided using the Ligasure or the Harmonic scalpel. Both ureteric ends were divided and sent for frozen section. The urethra was cut 1 cm from the bladder neck with a scalpel and a frozen section was sent from the its distal end. A pre-taken four to six 3–0 Vicryl sutures were put at the urethral end during cutting at 2, 6, 8, 12 ± 4, 10 o’clock with direction out - in and was retained till the neo bladder anastomosis was accomplished. Then the neo bladder was constructed using a segment of the ileum extending 45–60 cm from a point 30 cm proximal to the Ileocecal junction. This segment was isolated with a vascular pedicle constructing a pouch in the form of U, S or W shape). Ureteric anastomosis was done then the pouch was brought to the urethra for urethral anastomosis. The pouch was tested for being water tight before closure. An omental flap was put over the pouch and the anastomotic line (Fig. 2). Post-operatively, the urethral catheter was removed after 6 weeks and patients were advised to start training for controlling micturition. Patient voiding patterns and continence were assessed by means of a questionnaire and personal interviews as well as a voiding diary. In addition, C.T. urography was used to assess the reflux and incontinence of the patient.

Fig. 1
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Dissection between UB, uterus

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Fig. 2
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Pouch creation with arrows pointing to ureteric implantation

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Postoperative Evaluation

The patients follow up program included a 3 months outpatient visits for oncologic and functional evaluation for the 1st post-operative year and 6 months visits after that. The methods of evaluation were as follow; from the functional point of view, patients were asked during the visit about continence (daytime and nighttime). In the case with incontinence, patients were asked about the amount of and frequency during day and night. Also they were inquired whether they can completely evacuate the neobladder. The Continence was determined as the patient feel dryness without the aid of drugs or pads. Also radiologic examination of the patient with urography was done half annually (Fig. 3 and 4). Sexual function was also evaluated. The patients and their husbands were asked about their concurrent relationships with each other and if there are any abnormalities. Also patients were asked about any urinary problems during or after the sexual intercourse, such as urine-leakage, hematuria, dyspareunia or lower abdominal pain.

Fig. 3
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C-T urographic examination showing the pouch with the two ureters

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Fig. 4
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Conventional urography showing the pouch with the uterus contataining an IUD

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Results

The Oncologic Outcome

The patient and tumor characteristics are presented in Tables 1 and 2. Definitive histopathology showed transitional cell carcinoma (TCC) in 12 patients (50 %), squamous cell carcinoma (SCC) in 10 patients (41 %) and adenocarcinoma in 2 patients (8.4 %). Definitive histopathology showed surprisingly advanced disease in one case. The postoperative definitive histopathology in this case showed a high stage tumor SCC,(pT3bN1M0) with positive lymphatic metastasis. In this case the advanced disease was neither recognized by preoperative CT nor recognized intra-operatively. Oncologic failure occurred in this patient in the form of local pelvic recurrence after 9 months although the patient was directed for adjuvant treatment, this patient died 15 months later. Another patient was missed in the follow up after 12 months post-operatively.The remaining 22 patients are still living free of disease with a mean follow-up of 48 months (range 36–58).

Table 1 Tumor characteristics
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Table 2 Patients characteristics
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Functional Outcome

Twenty two women were evaluated for the functional outcome. Daytime and nighttime continence were satisfactory in 21/22 (95.4 %) and in 20/22 (90.9 %) respectively. Neither chronic urinary retention nor pouch-vaginal fistula was noted in any patients. We used items of the Index of Female Sexual Function (IFSF) questionnaire. we found accepted lubrication in 20/22 (90.9 %), ability to achieve orgasm in 19/22 (86.4 %), maintained desire in 20/22 (90.9 %),dyspareunia in 3/22 (13.6 %). Vaginal intercourse could be achieved successfully after 6–10 weeks in all patients with acceptable degree of satisfaction for both partners. The functional evaluation of the pouch and reflux was assessed by the use of the conventional urography examination and computed urography examination (Fig. 4) with the result showing 4 patients out of 22 survived patients had a mild degree of the reflux but with normal renal function (18.2 %).

Complications (Table 3)

There were no perioperative deaths. The most frequent early complications were superficial surgical site infections in 4 patients (16.6 %). The other complications were ileal anastomosis leak in 2 patients (8.3 %) and treated conservatively so closure was achieved after10-14 days. There were no late complications. No hydronephrosis, neobladder-ureteral reflux, or deterioration of the renal function was observed in any of patients during the follow-up.

Table 3 Peri-operative data and outcome
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Discussion

The main goal of bladder cancer management is to cure the disease with preservation of the normal continence. Achieving an excellent functional response at the expense of compromising cancer cure is not acceptable and it is important to provide patients with the best possible functional outcome, as there is an obvious effect of poor urinary function on the quality of life [7]. The aim of orthotopic bladder reconstruction is to provide a compliant, low pressure continent urinary reservoir that may be emptied completely at socially convenient intervals [3]. Orthotopic neobladder replacement has now been established as an acceptable and desirable type of urinary diversion in a significant percentage of female patients. [8, 9].There is an evidence indicating that in female patients who fulfill the criteria for such procedure, preserving the vaginal wall during cystectomy with subsequent orthotopic neobladder reconstruction significantly decreases the risk of neobladder-vaginal fistula and might improve the functional results [3, 10] In our series, none of the patients developed neobladder-vaginal fistula with maintained plane between the posterior bladder wall and the anterior vagina. Moreover, preserving the gynecologic organs and pubourethral ligament is less likely to result in pelvic descent or prolapse. None of our patients encountered pelvic prolapse during the follow-up. Ali-El-Dein et al. [11] suggested that the pouch descent may lead to angulation of the uretero-intestinal junction with subsequent herniation of the posterior pouch wall (pouchocele) through the anterior vaginal wall. Although it is important to recognize that local recurrence remains a risk, after a median follow-up of 48 months, none of these patients had any recurrence involving the posterior margin at pathologic staging except one case which was mentioned. Our results cope with the results of Takuya Koie et 2010 and Ali-El-Dein et al. 2013 as they restricted selection of their cases [6, 7]. Furthermore, the vaginal vault length is preserved in terms of width and depth, which should contribute to improved functional outcome in patients who are sexually active. In comparison to results obtained by Zippe et al., our results showed a superior sexual satisfaction score parameters (Table 3). Zippe et al. mentioned diminished ability to achieve orgasm in 12/27 patients (45 %), a decreased lubrication in 11/27 patients (41 %), a decreased sexual desire in 10/27 patients (37 %), and dyspareunia in 6/27 patients (22 %). They reported that only 13/27 patients (48 %) were able to achieve a successful vaginal intercourse [12].

Conclusion

Cystectomy with preservation of the internal genital organs is feasible in female with early, solitary or T2 bladder cancer patients with satisfactory functional and oncologic outcomes with proper case selection.