Urethral cancer recurrence in female patients after radical cystectomy with orthotopic neobladder
Article published in Urologia Polska 2006/59/1.

authors

Zbigniew Wolski, Magdalena Mikulska-Jovanović

Katedra i Klinika Urologii Ogólnej, Onkologicznej i Dziecięcej Collegium Medicum UMK w Bydgoszczy

keywords

urethra, carcinoma, ileal neobladder in women

summary

Introduction. The orthotopic neobladder in selected women is currently the urinary diversion of choice after removing the bladder due to invasive bladder cancer, similarly as it is in men. This procedure is performed in a small number of clinical centers. The risk factors of urethral recurrence in women with the ileal nebladder were not precisely estimated.

The aim of the study. The evaluation of the frequency and risk factors of the urethral cancer recurrence in women after radical cystectomy, due to invasive bladder cancer, with creating an orthotopic neobladder.

Material and methods. Between 1995 and July 2005, 60 patients aged from 42 to 80 years underwent radical cystectomy due to bladder cancer T2-T4, N0-2,M0, G 2-3. The orthotopic neobladder (modo Studer) was performed in 38 women. Pathological stage pT2 was confirmed in 7 (18,4%), T3a in 7 (18,4%), T3b in 21 (55,3%), T4a in 3 (7,9%); lymph nodes metastases in 12(31%), grade of malignancy G2 in 16 (42%), G3 in 22 (58%). There was no patient with the urethra invasion of the bladder cancer in the preoperative and intraoperative histopathological examination, but in one patient with urethral recurrence the cancer was confirmed in a cutting line of the urethra in the final histopathological evaluation. All patients underwent radical urethra sparing cystectomy, with removing 2/3 anterior and lateral vagina walls and hysterectomy. The patients underwent control visits every 3-6 months during the follow-up, with complete evaluation of the urinary tract and the abdominal organs with the use of ultrasound, urethrocystoscopy, urodynamic examination and urine cytology. The follow up was 1-87 months (average 17.5).

Results. In 6 (15,8%) patients during the 2-23 months of follow-up, urethral recurrence was observed. In these patients, the primary bladder cancer localization involved lateral or anterior walls (3 patients), bladder triangle or/and bladder neck (2 patients), bladder triangle and posterior wall (1). In 5 it was a multifocal tumor. The size of the tumors in 5 patients was over 3 cm. The grade of malignancy G2 was confirmed in primary tumors in 4 and G3 in 2 patients. All recurrences developed within the first two years after the cystectomy. The first symptoms were repeated hematuria (3 patients), voiding difficulties (2 patients) and complete urinary retention in one case. In 2 patients, at the same time with the urethral recurrence, metastases were found. In 4 patients, urinary cytology was positive. The diagnosis of the cancer recurrence was confirmed during the urethrocystoscopy and transurethral electroresection of the tumor in urethro - vesical junction. All patients received systemic chemotherapy. The mean overall survival of these patients was 18 months (3-30 months). The discovery of the urethral recurrence preceded the cancer dissemination by 4 months on average (1 to 6). In the Fisher test the correlation between size and localization of the primary tumor and the recurrence of the urethra were not statistically significant.

Conclusions. The risk of the urethral cancer recurrence exists in spite of negative intraoperative frozen section of the urethra specimen.

Urethral recurrence in women after radical cystectomy is definitely an unfavorable prognostic sign. The primary localization of the tumor beside the urethra and the bladder neck does not exclude the possibility of the urethral recurrence after radical cystectomy.

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