Sexuality preserving cystectomy and neobladder: Initial results

Purpose: Standard cystectomy for bladder cancer in males and females includes removal of organs that are vital to normal sexual function. We report the initial results of modified cystectomy in males and females meant to preserve all sexual function, called sexuality preserving cystectomy and neobladder. Materials and Methods: Sexuality preserving cystectomy and neobladder consists of pelvic lymph node dissection followed by cystectomy alone with preservation of the vasa deferentia, prostate and seminal vesicles in males, and all internal genitalia in females. An ileal neobladder is anastomosed to the 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 growth 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. Further requirements are patient motivation for the preservation of sexual function, no prostate cancer and no cervical/uterine abnormalities. Preoperative evaluation in males involves prostate specific antigen measurement and transrectal 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 preoperative urodynamics. Erectile function is evaluated by RigiScan (UroHealth Systems, Inc., Laguna Niguel, California) nocturnal penile erection measurement. A short course of 20 Gy. external radiation therapy to the bladder is given shortly before surgery. No patient has been lost to followup, which involves repeat RigiScan examination and regular endoscopy. All patients were entered in a prospective clinical trial approved by the medical ethics 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 carcinoma 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 N1M0 in 1. Mean followup was 3.5 years (range 3 to 6). Two patients died of widespread metastasis without local recurrence. In 1 case prostate cancer developed 5 years after sexuality preserving cystectomy and neobladder, which was treated with external radiation therapy. Erection was normal in 7 men with antegrade ejaculation in 5 and vaginal lubrication was reported to be normal in all women. Daytime continence was achieved in 9 of the 10 males and 2 of the 3 females, while nighttime continence was achieved in 7 and 2, respectively. One woman and 3 men perform intermittent catheterization because of post-void residual urine after voiding. Postoperatively a vaginal fistula and ureteral stenosis developed in I case each. Conclusions: Sexuality preserving cystectomy and neobladder achieves maximal tissue conservation, resulting in preserved normal sexual function and satisfactory urinary tract reconstruction. Using strict criteria oncological results have not been jeopardized to date.