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Objective: Treatment options in patients with persistent or locally recurrent cervical cancer are limited. The aim of this study was to determine the chance of cure and associated morbidity following pelvic exenteration., Patients and Methods: Consecutive patients who underwent pelvic exenteration between January 1992 and December 2006 at the University Hospital of Bern or the Karlsruhe Medical Center were evaluated. Time to recurrence, type of exenteration and urinary diversion, pathological stage, postoperative complications and survival were assessed., Results: Initial therapy prior to diagnosis of persistent or locally recurrent disease included radiation therapy in 51%. Anterior exenteration was performed in 37 (86%) and total exenteration in 6 (14%). Half of the women underwent additional procedures. A continent urinary diversion was constructed in 16 and an ileal conduit in 27 patients. Early postoperative complications were generally minor and only 2 patients required surgical intervention. Four intestinal fistulas were successfully treated conservatively. Late complications were mainly tumor-related. Complication rates associated with the urinary diversion were low and there was no difference in complications between continent and incontinent diversions. The overall disease-specific 5-year survival rate after exenteration was 36.5%. Survival correlated significantly with surgical margin status., Conclusion: In patients with persistent or locally recurrent gynecological malignancy of the pelvis, exenteration is a viable option with long-term survival in over one third of patients. Continent urinary diversion did not show higher complication rates than an ileal conduit and should be considered even in irradiated patients. This may be of greater significance in younger patients in whom an intact body image can play an important role in quality of life., (Copyright (c) 2010 S. Karger AG, Basel.)

The surgical technique described here is not more complex than that of an ileal conduit but has significant advantages. The aboral end of an isolated portion of the distal ileum is formed into a low pressure, high capacity bladder substitute that combines Goodwin's 'cup-patch' technique and Couvelaire's ileo-urethral anastomosis. Although the neobladder is constructed from only about 40 cm of ileum, it achieves a capacity of 500 ml within a few weeks, simultaneously with rapid improvement of urinary incontinence. The procedure described is easy to perform and its long-term functional results have passed the test of time. Aside from the surgical technique per se, success with this method of bladder substitution is mainly ascribed to meticulous postoperative care and follow-up.

Bladder substitution in women with transitional cell carcinoma (TCC) is not a universally accepted procedure. There are many concerns, one of which is the potential risk of metachronous and synchronous urethral transitional cell carcinoma involvement. Another concern is that voiding dysfunction may be more frequent than in male patients. The numbers of female patients who have had this procedure are still small, and follow-up data are relatively brief. Thus, the true role for orthotopic bladder substitution in the female is still being evaluated. This paper reviews the data on this type of surgery in women, with emphasis on urethral TCC risk and on voiding dysfunction. Early results from a number of institutions are encouraging, particularly in correctly selected patients. Based on more than 15 years experience in an albeit small number of patients, we believe that if there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.

Purpose: We present the long-term results of orthotopic bladder substitution in women., Materials and Methods: We prospectively assessed 15 female patients undergoing orthotopic bladder substitution between October 1984 and April 1998. The indication for diversion was bladder carcinoma in 8 cases, gynecologic malignancy in 2 and benign disease in 5., Results: At a median followup of 19 months daytime and nighttime continence was 100% and 80%, respectively. All but 1 patient voided spontaneously. Two patients who were initially able to void successfully had voiding difficulties in the initial 10 months due to prominent mucosal tissue at the bladder neck. In each case this condition was successfully managed by endoscopic resection. There has been no local recurrence of bladder carcinoma., Conclusions: With strict selection criteria and vigilant followup female orthotopic bladder substitution produces excellent long-term functional results comparable to those in men. However, the limits in women who require radical cystectomy for invasive bladder cancer cannot be determined from our results. Further long-term data on the local recurrence rate of invasive urothelial malignancy are needed before the true risk may be quantified accurately.

Objectives: A low-pressure ileal bladder replacement does not have any coordinated contraction during micturition, which is why we have evaluated various antireflux mechanisms in the context of a randomized prospective study., Material and Methods: 70 patients undergoing low-pressure ileal bladder replacement were randomized into 2 groups. An antireflux mechanism was performed in 35 patients and an afferent tubular segment was performed in the other 35 patients., Results: After a median follow-up of 57 and 45 months respectively, the functional capacity of the reservoir, incidence of urinary tract infections, urinary continence, voiding havits, and serum urea and creatinine were similar in the two groups. 11/67 (16.5%) evaluable ureteropelvic units with an antireflux mechanism and 2/69 (3%) units with an afferent tubular segment developed major dilatation due to stenosis of the antireflux mechanism or the ureteroileal anastomosis (Fisher's exact test, p < 0.009). No radiological reflux could be demonstrated during micturition in either group. A simultaneous increase of intravesical, intraabdominal and intrapelvic pressure was observed during a Valsalva manoeuvre., Conclusion: Protection of the upper urinary tract by an ileal afferent tubular segment has yet to be confirmed in a larger series of patients with a longer follow-up. Our results show that prevention of reflux is less important in the case of orthotopic low-pressure ileal bladder replacement. Consequently, creation of an antireflux mechanism, associated with a high complication rate, is probably not justified.

New insights into bladder cancer mechanisms have not yet produced clinical benefit. Without novel treatments, cystectomy remains the most effective local treatment, albeit the most aggressive. Uncertainty about the natural history of bladder cancer, the progression rate after other treatments, the risks of cystectomy and subsequent quality of life, foster debate about the indications for cystectomy. There are numerous urinary diversions and bladder substitutes. Differences in tumour extent, patient age, performance status, renal and mental function, and acceptance make different diversion techniques necessary. Urologists need not know every technique, but should know at least one technique of each class: an incontinent diversion (such as the ileal conduit), ureterosigmoidostomy, continent reservoir, and orthotopic bladder substitute. The common principles, advantages, and contraindications of these techniques are discussed.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.

Cutaneous urinary diversion requires appliances, unless a pouch and a valve mechanism are used (Kock-pouch). In order to avoid a stoma, repeated self-catheterizations, and the complications which may occur from malfunction of the distal valve, we created a modified ileal pouch with the advantages of a low-pressure system with good capacity and no reflux. By anastomosing the distal part of the reservoir to the urethra and using the male patient's own sphincter, the second nipple can be avoided and a urostoma is obviated. The feasibility of this procedure has been studied in 4 dogs.

At the beginning of this century it was realised that peristalsis would cause incontinence if bowel was used for augmentation or substitution of the bladder. Trans-section of the antimesenteric border and cross-folding of the intestinal segments (Goodwin's cup-patch technique) is an efficient means of solving this problem and has been successfully used in the Kock pouch. We anastomosed the ileal low pressure reservoir to the membranous urethra in 22 male patients following radical cystoprostatectomy for bladder cancer. The mean observation time was 16 months (range 3-36). The capacity of the bladder substitute increased with time, the average being 450 ml after 6 months. In the first 4 patients with a short (2-5 cm) intestinal segment between the pouch and the urethra, micturition was prolonged, residual urine varied from 50 to 300 ml and bacteriuria was found. Occasional expulsions of several ml of urine were caused by peristalsis within this short tubular segment. In the following 18 patients, the low pressure reservoir was anastomosed directly to the membranous urethra. Micturition was good, with no notable residual urine, no bacteriuria and no paroxysmal urinary incontinence. However, a safety pad is used by half of the patients because once or twice a week, mainly at night, a few ml of urine may be lost. No significant changes in serum electrolytes, bicarbonate or creatinine were noted. With the three different antireflux techniques used, no obstructive or inflammatory changes in the upper urinary tracts were found, although no long-term antibiotic prophylaxis was given.

In certain functional disorders of the urinary bladder or invasive carcinoma, cystectomy with urinary diversion to the abdominal wall (urostomy) is indicated and life-prolonging. In order to know what the consequences were for these patients, and if their life with a urostomy is still outwardly worth living, 66 of our urostomy patients have been surveyed. Only one patient is on a disablement pension because of the urostomy. The limitations on leisure are mostly the realms of sport and travel; married life, despite sexual problems, is comparatively little affected. The causes for the limitations are discussed. For most patients the urinary diversion brought an improvement in "life comfort", and, generally, it can be said that urostomy is not an disabling operation and psychosocial reintegration is possible.

An internal urinary diversion after radical cystoprostatectomy has been performed in 24 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 3 months to 3 years, the results are in general good: no signs of pyelonephritis or metabolic changes, necessitating a substitution, have been observed. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 2-6 months during the right. According to our experience, preservation of the neurovascular bundles responsible for erection, helps to regain continence. However, loss of several drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night.