Neobladder with prostatic capsule and seminal-sparing cystectomy for bladder cancer: A step in the wrong direction

The initial intent of bladder replacement procedures was not to improve survival or prognosis, or to decrease renal and metabolic complications, but rather to improve the quality of life. The success of total bladder substitution largely depends on the degree of continence that the patient is able to achieve. Although good daytime continence was reported with most techniques, some patients had a high voiding frequency and occasionally were wet at night, unless they voided more frequently or used a collection device. Preservation of apical prostatic tissue or the prostatic capsule for anastomosis with a reservoir has been suggested by several authors to improve urinary continence at a time when orthotopic reconstruction was experimental surgery and the currently used technical principles of neobladders were unknown [1-5]. It was assumed that preservation of the prostatic apex would improve urinary continence in orthotopic reservoirs based on the following rationale: this part of a prostate contains the inner smooth muscle component of a distal urethral sphincteric mechanism [6], which presumably augments the external striated muscle component in maintaining continence. Theoretically, continence in these patients would be better than in those with complete resection of the prostate. Complete removal of the prostate versus partial preservation can be considered from three aspects: (1) the possibility of violating the principles of oncologic surgery, (2) the effects on continence, and (3) the effect on sexuality. This article analyzes recent results in sexual function preserving cystectomy, including indications, risks, and outcome.