Until recently continent neobladders - which retain normal voiding function through the urethra - were rarely offered as an option for women, mainly due to the perceived risk of local tumor recurrence and urinary incontinence. The pathologic implications of preserving the female urethra had not been well studied. Recent studies have addressed both of these issues, resulting in a better understanding of the continence mechanism in women as well as a better understanding of the risk factors for urethral tumor involvement in women with bladder cancer. Consequently, orthotopic lower urinary tract reconstruction has become an accepted option for women undergoing cystectomy.

The concern of an elevated risk of urinary incontinence has proved to be unfounded; in fact the major concern is an increased risk of urinary retention with approximately 20% of women requiring long-term intermittent catheterization. The perceived high risk of local recurrence has been shown to be false in carefully selected women whose tumors do not involve the bladder neck, which is the only significant risk factor for urethral tumor involvement.

Retrospective long-term observations of female patients with primary bladder cancer revealed as low as 2% incidence of secondary urethral tumors.1 Brady Institiute experts' review of pathological specimens over a 13 year period have also found that sacrifice of the urethra and anterior vaginal wall is not always necessary from an oncological perspective.2 They conclude that neobladders are particularly appropriate in women concerned with postoperative sexual function.

Risk Factors
Women with high stage/high grade tumor at trigone area of the bladder, and any stage/grade involvement of the bladder neck (the junction of the bladder and the urethra) are at high risk of urethral recurrence after radical cystectomy and orthotopic neobladder procedure.

If the urethral margins demonstrate tumor on frozen section, orthotopic neobladder reconstruction should be abandoned in favor of urethrectomy and an alternative form of urinary diversion. Because the final decision on whether or not to proceed with orthotopic diversion to the urethra rests upon the results of the intraoperative frozen section (biopsy), it is important that to be advised preoperatively of alternative diversion methods, including both continent and noncontinent forms of cutaneous urinary diversion.

Expert John Stein and colleagues also include preoperative biopsy at the bladder neck and anterior vaginal wall as well as a negative intraoperative frozen section of the proximal urethra. Such precautions seem to be successful: of 34 women undergoing orthotopic reconstruction to the urethra, at median follow-up of 18 months after cystectomy there were no urethral tumor recurrences reported. 3 4

Early results have been encouraging and suggest that neobladders are a good option for up to 75-85% of women undergoing cystectomy. Complications are few and continence is maintained in most patients. In fact, it may be hypercontinence (retention of urine) and not incontinence, that becomes the major problem as these women continue to be followed after cystectomy. The procedure has resulted in a high level of patient satisfaction which is hoped will encourage patients to consider earlier, more aggressive treatment of invasive bladder cancer in women.

Experts in the field of neobladders for women, Drs. Alan Doherty, Fiona Burkhard and Stephan Holliger, MD write in their article 'Bladder Substitution in Women' that nerve-sparing surgery must be performed in order to save the nerve supply to the pelvic organs so as to "maximize the likelihood of retaining a voiding reflex as well as preventing loss of tone in the proximal urethra."

Voiding function is a major concern. About a third of women will be fully continent, a third suffer from incontinence and the other third experience hypercontinence.

Women who experience incontinence can benefit from the injection of bulking agents into the urethra. Women who are hypercontinent will need to self-catheterize. An alternative to self catheterization is a manual technique described by a survivor here.

Hypercontinence may be explained by nerve loss/damage to the lower third of the urethra during surgery. Chronic retention can also be caused by hypertrophy (enlargening) of mucosal folds at the anastomosis, where the ureters have been re-connected. This can be diagnosed with urethroscopy and treated by endoscopic resection. Another possible explanation may be that the gradual sinking of the newly constructed pouch results in a 'fallen bladder'.5

After surgery
Neobladder recipients must be strongly motivated and able to continue meticulous management at home, the aim being to:

• Prevent residual urine
• Prevent infection
• Prevent acidosis
• Expand the pouch
• Encourage drinking and salt intake for the first month

Initially, patients are instructed to void every 2 hours, first by sitting while relaxing the pelvic floor and, if necessary, by abdominal straining without pressing downward. Patients without metabolic disturbances are instructed to retain urine for 3 and then 4 hours. Patients are told not to be despondent by episodes of incontinence or dribbling. Usually, incontinence occurs during periods of high intravesical pressure and is more common when the pouch capacity is small (Laplace's law). Most patients find it easy to understand that high intravesical pressure is required to expand the reservoir. In this way, a bladder capacity of 500 mL can be reached, and continence will ensue. Many patients find this regimen difficult to adhere to. They fear incontinence and urinate frequently. The bladder remains of small capacity, and persistent nocturnal incontinence is inevitable.

Patients are told to avoid alcohol and sleeping pills because these relax the pelvic floor, which in turn leads to incontinence.5

References
1. Semin Urol Oncol 2001 Feb;19(1):9-17 VI--choosing the right reconstruction for your female patients.Stenzl A, Strasser H, Hobisch A, Bartsch G.Department of Urology, University of Innsbruck, Austria.PMID: 11246739

2.Anatomical anterior exenteration with urethral and vaginal preservation: illustrated surgical method. Schoenberg M, Hortopan S, Schlossberg L, Marshall FF.James Buchanan Brady Urological Institute and Johns Hopkins Oncology Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. Urol 161:569-572, February, 1999. J Urol 1999 Feb;161(2):569-72 PMID: 9915450

3.World J Urol 1996;14(1):9-14 The use of orthotopic neobladders in women undergoing cystectomy for pelvic malignancy.Stein JP, Stenzl A, Grossfeld GD, Freeman JA, Esrig D, Boyd SD, Lieskovsky, Bartsch G, Skinner DG.Department of Urology, University of Southern California Medical Center, Los Angeles 90033, USA. Pub Med abstract

4. Stein JP, Grossfeld GD, Freeman JA, et al. Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 34 patients. J Urol. Pub Med abstract

5. Alan Doherty, MD, Fiona Burkhard, MD, Stephan Holliger, MD, and Urs Studer, MD Bladder Substitution in Women Current Oncology Reports 2001, 2:350-356 Current Science, Inc. ISSN 1523-3790 Copyright © 2004 by Current Science, Inc.