Rationale for bladder-sparing surgery in patients with locally advanced colorectal carcinoma

BACKGROUND. Total pelvic exenteration (TPE) with urinary diversion is a sta ndard surgical approach for patients with locally advanced rectal carcinoma . Because only approximately 50% of patients undergoing TPE have tumor invo lving the bladder, the authors evaluated the feasibility of bladder salvage in this setting. The current study presents the results of a retrospective study of patients with advanced colorectal carcinoma (classification of gr eater than or equal to T3) to formulate criteria for selecting patients for bladder-sparing procedures. METHODS, The charts of 81 patients with rectal carcinoma classified as grea ter than or equal to T3 were reviewed for age, gender, computed tomography (CT) findings, results of intraoperative examination under anesthesia, fina l pathologic evaluation, urologic complications, local recurrence, and pati ent survival. RESULTS, Among the 46 patients who underwent TPE, final pathologic evaluati on demonstrated tumor involvement of the bladder in 58% of patients. Preope rative identification of a bladder mucosal abnormality accurately predicted bladder involvement in only 57% of the 30 patients who underwent cystoscop y. CT and intraoperative palpation of the bladder individually predicted th e final pathologic findings in 69% and 70% of patients, respectively; of th e 21 patients in whom both were positive, 90% had bladder involvement. Of t he 35 patients (26 females and 9 males) who underwent bladder-sparing proce dures, 22 had complete sparing of the bladder, 9 underwent partial cystecto my (5 with ureteroneocystostomy), 4 underwent ureteroneocystostomy alone, a nd 2 underwent prostatectomy alone. Ninety-four percent of these 35 patient s had negative histologic margins. There was no difference in the incidence rare of urinary complications between patients who underwent TPE and those who underwent a bladder-sparing surgery (17% each). The incidence rates of local recurrence (14% vs. 17%) and the 3-year survival rates (49% vs. 39%) did not differ significantly between the 2 groups. CONCLUSIONS. Bladder-sparing surgery to treat patients with locally invasiv e colorectal carcinoma provides good local control without sacrificing surv ival. Women, whose reproductive organs act as a natural barrier, and select ed men in whom CT and intraoperative evaluation identify only localized inv olvement of the prostate or bladder appear to be reasonable candidates for bladder-sparing procedures. (C) 1999 American Cancer Society.