Gynecologic-tract sparing extra peritoneal retrograde radical cystectomy with neobladder

Outcomes after robot-assisted radical cystectomy with orthotopic neobladder in women

PURPOSE

To investigate functional, oncological and complication outcomes in women undergoing robot-assisted cystectomy (RARC) with intracorporeal orthotopic neobladder.

METHODS

From a multi-institutional database, we identified females with bladder cancer treated with RARC and intracorporeal orthotopic neobladder. We evaluated the continence rate, short-term oncological outcomes, and complication rates. Analyses were repeated and stratified by the status of preserving gynecological organs.

RESULTS

The study involved 146 patients with the median age 60 years (IQR, 51-66 years). Pelvic organ-preserving procedure (POP) was performed in 77 patients (53%). Overall daytime and nighttime continence rates were 54% and 53%, respectively. For POP, the continence rate was 58% for both daytime and nighttime continence. In the non-POP cohort, the continence rate was 50% for daytime and 49% for nighttime continence. Both groups had balanced positive surgical margin rates (5,3% for POP and 4,7% for non-POP). In the whole cohort, high-grade (Clavien-Dindo ≥3) early and late complication rate was 7,5% and 7,5%, respectively.

CONCLUSIONS

Robot-assisted radical cystectomy with intracorporeal orthotopic neobladder in females demonstrate excellent functional and complication outcomes. Pelvic organ-preserving cystectomy enhances urinary continence rates without adversely affecting surgical margins. Orthotopic neobladder in selected women with bladder cancer, along with pelvic organ-preserving cystectomy may be used for improved functional outcomes without compromising oncological results.

Pelvic organ-preserving radical cystectomy versus standard radical cystectomy in female patients diagnosed with bladder cancer

BACKGROUND

Pelvic organ-preserving radical cystectomy (POPRC) has been reported to result in a better postoperative quality of life in female with bladder cancer compared to standard radical cystectomy (SRC). However, its oncological outcomes remain a concern.

PATIENTS AND METHODS

Female patients with bladder cancer who underwent POPRC or SRC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression was used to identify predictors of POPRC usage. To avoid the potential impact of baseline differences between groups on survival, a 1:2 propensity score matching (PSM) was implemented. After that, Kaplan-Meier curves and Log-rank tests were used to determine the significance of overall survival (OS) differences between patients in the SRC group and POPRC group. Finally, subgroup analysis based on predetermined indicators was performed.

RESULTS

A total of 2193 patients were included with a median follow-up of 53 months, of whom 233 (10.6%) received POPRC and 1960 (89.4%) received SRC. No definitive predictors of POPRC were identified. Before PSM, POPRC resulted in comparable OS to SRC (HR = 1.09, p = 0.309), while after PSM, POPRC was associated with significantly worse OS (HR = 1.23, p = 0.038). In subgroup analyses, POPRC led to non-inferior OS (HR = 1.18, 95%CI 0.71-1.95, p = 0.531) in patients with non-muscle invasive bladder cancer (NMIBC) and T2 patients (HR = 1.07, p = 0.669), but significantly worse OS in T3 patients (HR = 1.41, p = 0.02).

CONCLUSION

Currently, patients undergoing POPRC have not undergone strict screening, and candidates for POPRC should have more stringent criteria in the future to achieve satisfactory oncological outcomes. However, flaws in the study make more evidence needed to support our findings.

Comparison of functional and oncological outcomes between uterus-sparing radical cystectomy and standard radical cystectomy in females: A retrospective study

Purpose

This study aimed to compare the functional and oncological outcomes of females who underwent uterus-sparing radical cystectomy (USRC) and standard radical cystectomy (SRC).

Materials and Methods

Between February 2009 and December 2020, 90 female patients who underwent radical cystectomy with urinary diversion were included in this study, comprising the USRC and SRC groups. Functional outcomes were assessed in 63 patients who only underwent radical cystectomy with neobladder formation. Questionnaire scores, clean intermittent catheterization (CIC) rate, and urinary continence rate were analyzed. Oncological outcomes were assessed in 86 patients, regardless of the urinary diversion type. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were compared.

Results

CIC rate was significantly lower in the USRC group than in the SRC group (14.7% vs. 48.0%; p=0.005). The continence rate was significantly higher in the USRC group than in the SRC group (85.3% vs. 40.0%; p=0.001). There were no significant differences in OS (p=0.890), CSS (p=0.700), or RFS (p=0.270) between the two groups. In multivariate analysis, uterine preservation did not significantly increase the hazard ratio (HR) of OS (HR, 0.62; 95% CI, 0.18–2.11; p=0.450), CSS (HR, 0.99; 95% CI, 0.22–4.40; p=0.990), or RFS (HR, 0.46; 95% CI, 0.19–1.11; p=0.840).

Conclusions

USRC resulted in higher continence rates and lower CIC rates than SRC without negatively affecting oncological outcomes. Hence, with thorough deliberation, USRC should be considered for females undergoing radical cystectomy.

Safety and Efficacy of Reproductive Organ-Sparing Radical Cystectomy in Women With Variant Histology and Advanced Stage

PURPOSE

Muscle invasive bladder cancer surgical management has been historically a radical cystoprostatectomy in males and an anterior exenteration in females. Uterine, ovarian, and vaginal preservation are utilized, but raise concerns regarding risk to oncologic control, especially in variant histopathology or advanced stage.

MATERIALS AND METHODS

A retrospective single institutional analysis identified radical cystectomies performed in women, including those with variant histology, which were defined as reproductive organ sparing (uterine, vaginal, and ovary sparing) or nonorgan sparing. The Kaplan-Meier method was used for recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in patients with advanced disease.

RESULTS

From 2000 to 2020, 289 women were identified, 188 underwent reproductive organ-sparing cystectomy. No statistical differences were noted for clinical parameters or presence of variant histology for organ-sparing (ROS) and nonorgan-sparing (non-ROS). Positive margin rates did not differ for ROS and non-ROS; 4.3% vs. 7.9%, P = .19, respectively. Median RFS was not statistically significantly different for ROS vs. non-ROS (26.1 vs. 15.3 months) P = .937 hazard ratio (HR) 1.024. CSS was not statistically different for ROS vs. non-ROS (36.3 vs. 28.6 months), P = .755 HR 0.9. OS was not statistically different for ROS vs. non-ROS (25.8 vs. 23.8 months), P = .5 HR = 1.178. Variant histology did not change survival (HR 1.1, P = .643).

CONCLUSION

In this analysis, ROS in women with advanced disease did not increase positive margin rates or decrease RFS, CSS, or OS compared to non-ROS. Variant histology did not decrease survival odds. Based on preoperative assessment and intraoperative findings, ROS in patients with variant histology and advanced disease should be considered.

Genitalia Preserving Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation in the Female: Experience in 5 Cases

We present operative, postoperative, oncologic and functional outcomes of genital tract sparing robot-assisted laparoscopic radical cystectomy, bilateral extended pelvic lymph node (LN) dissection and intracorporeal Studer pouch construction on five female patients with bladder cancer. One of the cases had concomitant nephroureterectomy performed due to a non-functioning kidney. Median patient age, mean operation time, median estimated blood loss and mean duration of hospital stay were 59 (39–78), 462 ± 25, 400 (50–970), 8.8 ± 2.5, respectively. Pathologic stages were pTis (n=1), pT1 (n=1), pT3 (n=1), pT4a (n=1) and pT4b (n=1). Mean LN yield was 32.4 ± 8.9. Positive surgical margins were detected in 2 patients with pT4 diseases. Only minor complications developed that were resolved with medical treatment. Two patients had no, 1 patient had mild, and 2 patients had moderate daytime incontinence. One patient had good, 3 patients had fair, and 1 had poor night-time incontinence. This complex robotic surgery can be performed safely with acceptable short-term surgical, oncological and functional outcomes.

Correlates of refusal of radical cystectomy in patients with muscle-invasive bladder cancer

PURPOSE

To evaluate factors associated with radical cystectomy (RC) refusal, subsequent treatment decisions, and their influence on overall survival (OS).

MATERIALS AND METHODS

We queried the National Cancer Database for patients with non-metastatic muscle-invasive bladder cancer (MIBC), cT2-T4M0. Patients who refused recommended RC were further stratified by treatment into chemotherapy, radiation therapy, chemoradiotherapy, and no treatment groups. Patients were excluded from the analysis if surgery was not planned, not recommended; or if survival data were unknown. Multivariate logistic regression modeling was utilized to identify independent predictors of refusing RC. Cox proportional hazards model with propensity score overlap weighting was utilized to identify survival predictors. Kaplan-Meier analysis was utilized to evaluate survival according to treatment.

RESULTS

A total of 74,159 MIBC patients were identified. Among patients with documented reasons for no surgery, 5.4% refused RC despite physician recommendation. Predictors of refusal on multivariate analysis included female gender (P = 0.016), advancing age ≥80 (vs. <60, P < 0.001), African American race (vs. white, P < 0.001) Medicaid (vs. private insurance, P < 0.001) and advancing T stage (T4 vs. T2, P < 0.001). Patients treated at academic centers were less likely to decline RC (vs. community centers, P < 0.001). Median survival after RC was 40.44 months vs. 12.52 months in refusal group. Undergoing chemoradiation had significantly improved survival in those patients compared to monotherapy or no treatment (hazard ratio 0.25, P < 0.001). Overlap weighted model Identified RC refusal as an independent predictor of poor OS (P < 0.001).

CONCLUSIONS

Several sociodemographic and clinical factors are associated with refusing radical cystectomy. Such refusal is associated with poor survival outcomes.

Gynecological organ involvement at robot-assisted radical cystectomy in females: Is anterior exenteration necessary?

INTRODUCTION

We aimed to investigate patient and disease variables associated with gynecological organ invasion in females with bladder cancer at the time of robot-assisted radical cystectomy (RARC).

METHODS

We conducted a retrospective review of female patients who underwent robot-assisted anterior pelvic exenteration (RAAE) between 2005 and 2016. Patients were divided into two groups: those with gynecological organ involvement at RAAE and those without. Data were reviewed for perioperative and pathological outcomes. Kaplan-Meier method was used to depict survival outcomes. Multivariable stepwise regression analysis was performed to identify predictors of gynecological organ involvement.

RESULTS

A total of 118 female patients were identified; 17 (14%) showed evidence of gynecological organ invasion at RAAE. Patients with gynecological organ invasion had more lymphovascular invasion at transurethral resection of bladder tumour (TURBT) (82% vs. 46%; p=0.006), trigonal tumours at TURBT (59% vs. 18%; p=0.001), multifocal disease (65% vs. 33%; p=0.01), pN+ (71% vs. 22%; p<0.001), positive surgical margins (24% vs. 4%; p=0.02), and they less commonly demonstrated pure urothelial carcinoma at TURBT (18% vs. 66%; p<0.001). On multivariate analysis, significant predictors of gynecological organ invasion were pN positive disease (odds ratio [OR] 6.48; 95% confidence interval [CI] 1.64-25.51; p=0.008), trigonal tumour location (OR 5.72; 95% CI 1.39-23.61; p=0.02), and presence of variant histology (OR18.52; 95% CI 3.32-103.4; p=0.001).

CONCLUSIONS

Patients with trigonal tumours, variant histology, and nodal involvement are more likely to have gynecological organs invasion at RAAE. This information may help improve counselling of patients and better identify candidates for gynecological organ-sparing cystectomy.

Role and Indications of Organ-Sparing "Radical" Cystectomy: The Importance of Careful Patient Selection and Counseling

Organ-sparing cystectomy remains an operation for a highly selected patient population that can offer similar oncologic outcomes but improved sexual function in men and women. Occult prostate cancer in men may occur even with screening but the majority is of clinical insignificance. Paramount to patient selection are oncologic concerns, but preoperative sexual function, age, performance status, and postoperative expectations must also be evaluated during patient selection. Improved diagnostic and surveillance tools may facilitate and improve patient selection in the future.

Systematic review of the oncological and functional outcomes of pelvic organ-preserving radical cystectomy (RC) compared with standard RC in women who undergo curative surgery and orthotopic neobladder substitution for bladder cancer

CONTEXT

Pelvic organ-preserving radical cystectomy (POPRC) for women may improve postoperative sexual and urinary functions without compromising the oncological outcome compared with standard radical cystectomy (RC).

OBJECTIVE

To determine the effect of POPRC on sexual, oncological and urinary outcomes compared with RC in women who undergo standard curative surgery and orthotopic neobladder substitution for bladder cancer.

EVIDENCE ACQUISITION

Medline, Embase, Cochrane controlled trials databases and clinicaltrial.gov were systematically searched for all relevant publications. Women with bladder cancer who underwent POPRC or standard RC and orthotopic neobladder substitution with curative intent were included. Prospective and retrospective comparative studies and single-arm case series were included. The primary outcomes were sexual function at 6-12 months after surgery and oncological outcomes including disease recurrence and overall survival (OS) at >2 years. Secondary outcomes included urinary continence at 6-12 months. Risk of bias (RoB) assessment was performed using standard Cochrane review methodology including additional domains based on confounder assessment.

EVIDENCE SYNTHESIS

The searches yielded 11 941 discrete articles, of which 15 articles reporting on 15 studies recruiting a total of 874 patients were eligible for inclusion. Three papers had a matched-pair study design and the rest of the studies were mainly small, retrospective case series. Sexual outcomes were reported in seven studies with 167/194 patients (86%) having resumed sexual activity within 6 months postoperatively, with median (range) patients' sexual satisfaction score of 88.5 (80-100)%. Survival outcomes were reported in seven studies on 197 patients, with a mean follow-up of between 12 and 132 months. At 3 and 5 years, cancer-specific survival was 70-100% and OS was 65-100%. In all, 11 studies reported continence outcomes. Overall, the daytime and night-time continence rates were 58-100% and 42-100%, respectively. Overall, the self-catheterisation rate was 9.5-78%. Due to poor reporting and large heterogeneity between studies, instead of subgroup-analysis, a narrative synthesis approach was used. The overall RoB was high across all studies.

CONCLUSION

For well-selected patients, POPRC with orthotopic neobladder may potentially be comparable to standard RC for oncological outcomes, whilst improving sexual and urinary function outcomes. However, in women undergoing RC, oncological and functional data regarding POPRC remain immature and require further evaluation in a prospective comparative setting.

Orthotopic genital sparing radical cystectomy in pre-menopausal women with muscle-invasive bladder carcinoma: A prospective study

INTRODUCTION

Invasive cancer bladder is a life-threatening disease that is best treated with radical cystectomy and a suitable urinary diversion. The aim of this study was to evaluate the oncological outcome, voiding and sexual functions after genital sparing radical cystectomy with orthotopic bladder reconstruction in pre-menopausal women with bladder cancer.

MATERIALS AND METHODS

18 pre-menopausal women who underwent radical cystectomy and orthotopic urinary diversion with preservation of genital organs were included for this study. The patients were followed-up clinically and radiologically to assess their oncological outcome in addition to their voiding and sexual function.

RESULTS

Mean age of the patients was 37.8 years, and the median follow-up after surgery was 70 months. One patient was lost to follow-up at 12 months post-operatively. The surgery was completed as planned in all patients, with a mean operative time of 290 min and an average blood loss of 750 mL. 14 patients were able to void satisfactorily, being continent day and night, while four patients needed clean intermittent catheterization. Sexual life remained unchanged in 15 cases, while three patients reported dysparunea. Till the last follow-up, there was no local recurrence while distant metastases were detected in three cases, two of whom died.

CONCLUSIONS

Genital sparing cystectomy is a valid option for managing carefully selected women with muscle-invasive bladder cancer with good functional and sexual outcomes.

Genital Sparing Cystectomy for Female Bladder Cancer and its Functional Outcome; a Seven Years' Experience with 24 Cases

The surgical treatment of bladder cancer is the curative treatment especially in early cases. In this study, our aim was to assess the outcome of preservation of internal genital organs in selected females both oncologically and functionally, and to assess the feasibility of technique and its complication. 24 females with clinically and radiologically diagnosed T2 bladder cancer underwent gynecologic-tract sparing cystectomy (GTSC). Age ranged from 45 to 60 years. Patients with diffuse carcinoma-in-situ, those with tumors involving the bladder neck, those with poor general condition and those with preoperative incontinence were excluded. 1 patient, who developed local recurrence after 6 months. One patient lost follow up after 15 months. No recurrence developed in the retained genital organs. The remaining 20 patients remained free of disease. Among women who were eligible for functional evaluation, Daytime and nighttime continence were satisfactory in 21/22 (95.4 %) and in 20/22 (90.9 %) respectively. Chronic urinary retention, pouch-vaginal fistula was not noted. Most of patients showed superior Sexual Function index. Cystectomy with preservation of the internal genital organs is feasible in female with early, solitary or T2 bladder cancer with satisfactory functional and oncologic outcomes with proper case selection.

Primary and secondary malignant involvement of gynaecological organs at radical cystectomy for bladder cancer: review of literature and retrospective analysis of 360 cases

The pathological analysis of cystectomy specimens from 360 female patients who underwent radical cystectomy for bladder cancer was retrospectively reported. The uterus was not available in 29 specimens, while one ovary was absent in 18 specimens and the two ovaries were absent in 20 specimens. Uterine involvement was observed in one case of transitional cell carcinoma, and benign uterine pathology was detected in 37 cases. All patients had normal ovaries, while the vagina was involved in 13 cases. A total of 12% of the patients had urethral involvement. None of the 29 patients, in whom the internal genitalia were totally or partially preserved, had late ovarian, vaginal or uterine recurrence at the last follow-up. Thus, the preservation of female internal genitalia in young patients undergoing radical cystectomy should be considered under strict criteria (low-grade, low-stage tumours away from the bladder neck). This will improve the quality-of-life (QoL) and the functional outcome without compromising cancer control.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.