Urinary diversion in women following radical cystectomy: single center comparison and update on outcomes

Introduction & Objectives: Radical cystectomy remains the primary treatment for highgrade, invasive bladder cancer. Over the past twenty years, the various options for lower urinary tract reconstruction in women have clearly evolved. The clinical outcomes of incontinent cutaneous (IC), continent cutaneous (CC), and orthotopic neobladders (ON) for females following radical cystectomy are reviewed. Material & Methods: From July 1971 to December 2004, 327 females, ages 23 to 91 years old (median age 67) with primary Transitional Cell Carcinoma of the bladder underwent radical cystectomy and urinary diversion. Urinary diversion was performed by means of ON in 115, CC diversion in 121, and IC diversion by means of ileal conduit in 91 patients. Data were analyzed according to histologic grade and pathologic stage, presence of carcinoma in situ, multifocal carcinoma, lymphovascular invasion, lymph node density, early and late complications, pre-operative radiation, overall and recurrence-free survival. Results: Median follow-up for the entire cohort is 12.2 years (range: 8 days to 33.6 years). All patients receiving pre-operative radiation therapy underwent continent diversions (71% IC vs. 29% CC vs. 0% ON; p < .0001). Furthermore, although higher grade tumors were more commonly seen in the cutaneous diversion groups (89% vs 75%; p=0.001) the presence of multifocal tumor, carcinoma in situ, or advanced patient age (> 65 years old) did not have an influence the type of diversion performed. There were no significant differences in pathological stage, presence of lymphovascular invasion, margin status, lymph node density, early complication rate, and operative mortality between the three groups. Despite a higher late complication rate with orthotopic diversions (p < .0001), the type of diversion did not have a statistically significant impact on overall survival or recurrence. Conclusions: Orthotopic diversion is an appropriate form of urinary diversion in carefully selected women with bladder cancer. When comparing various forms of reconstruction, there are no apparent pathological differences and the survival data are similar. From an oncological perspective, women undergoing an orthotopic diversion are not compromised with this form of diversion. Further functional studies addressing quality of life issues and continence status are needed to validate these clinical outcomes