Sexuality preserving cystectomy and neobladder: Initial results

Purpose: Standard cystectomy for bladder cancer in males and females includ es removal of organs that are vital to normal sexual function. We report th e initial results of modified cystectomy in males and females meant to pres erve all sexual function, called sexuality preserving cystectomy and neobla dder. Materials and Methods: Sexuality preserving cystectomy and neobladder consi sts of pelvic lymph node dissection followed by cystectomy alone with prese rvation of the vasa deferentia, prostate and seminal vesicles in males, and all internal genitalia in females. An ileal neobladder is anastomosed to t he margins of the prostate in males and urethra in females. Indications for this type of surgery are bladder cancer stages T1-T3 with absent tumor gro wth in the bladder neck in males and females, absent tumor in the prostatic urethra in males and absent invasive tumor in the trigone in females. Furt her requirements are patient motivation for the preservation of sexual func tion, no prostate cancer and no cervical/uterine abnormalities. Preoperativ e evaluation in males involves prostate specific antigen measurement and tr ansrectal ultrasound with sextant prostate biopsies, while females undergo gynecological examination with a cervical smear and transvaginal ultrasound . Voiding and sexual function are assessed by a structured interview with p reoperative urodynamics. Erectile function is evaluated by RigiScan (UroHea lth Systems, Inc., Laguna Niguel, California) nocturnal penile erection mea surement. A short course of 20 Gy. external radiation therapy to the bladde r is given shortly before surgery. No patient has been lost to followup, wh ich involves repeat RigiScan examination and regular endoscopy. All patient s were entered in a prospective clinical trial approved by the medical ethi cs committee. Results: From 1995 to 1998, 10 males and 3 females 38 to 71 years old (mean age 55) were enrolled in this protocol. Bladder cancer was stage T carcino ma in situ N0M0 in 1 case, Ta multiple grade 3 N0M0 in 1, T1 multiple grade 3 N0M0 in 4, T2 grade 3 N0M0 in 5, T2 grade 3 N1M0 in 1 and T3 grade 3 N1M 0 in 1. Mean followup was 3.5 years (range 3 to 6). Two patients died of wi despread metastasis without local recurrence. In 1 case prostate cancer dev eloped 5 years after sexuality preserving cystectomy and neobladder, which was treated with external radiation therapy. Erection was normal in 7 men w ith antegrade ejaculation in 5 and vaginal lubrication was reported to be n ormal in all women. Daytime continence was achieved in 9 of the 10 males an d 2 of the 3 females, while nighttime continence was achieved in 7 and 2, r espectively. One woman and 3 men perform intermittent catheterization becau se of post-void residual urine after voiding. Postoperatively a vaginal fis tula and ureteral stenosis developed in I case each. Conclusions: Sexuality preserving cystectomy and neobladder achieves maxima l tissue conservation, resulting in preserved normal sexual function and sa tisfactory urinary tract reconstruction. Using strict criteria oncological results have not been jeopardized to date.