Introduction: Although orthotopic diversion with ileal neobladder is a well-established option for women undergoing radical cystectomy, functional outcomes are heterogenous and often hard to predict. Importantly, these outcomes have not been compared across female organ-sparing approaches. We aim to compare functional outcomes of patients undergoing anterior pelvic exenteration (APE), vaginal-sparing cystectomy (VSC), and female organ-sparing cystectomy (FOSC) and assess predictors of post-operative continence and retention.
Methods: Using our institutional review board approved bladder cancer database, we identified 73 female patients who underwent open radical cystectomy and orthotopic neobladder from 2010 to 2020. Patients with a minimum follow of 6 months were included in final analysis. Clinicopathologic information, including daily pad number, degree of wetness and catheter use were abstracted. Urinary retention was defined as =3 catheterisations/day or a self-reported inability to void without a catheter. Patients were considered continent if they reported no pad use or pads “almost dry” during a given time (day or night).
Results: A total of 57 female patients with adequate follow up were included. The median age was 65 years (IQR: 59-71). Of these, 32 (56%) had APE, 16 (28%) had VSC, and 9 (16%) had FOSC. Urinary retention was seen in 19/57 (33%) of patients, of whom 12/19 (63%) and 6/19 (31.5%) underwent APE and VSC, respectively, with a median time to retention of 12 months (IQR 7 -16.7).
Among patients not in retention (38/57, 66%), day and nighttime continence rates at 24 months post-operatively were 85% and 65% respectively. At one year following surgery, 85% of FOSC patients recovered daytime continence compared to 65% in APE and 64% in VSC (figure 1).
On univariate cox regression, history of vaginal delivery (HR 5, P=0.005) was associated with daytime incontinence. Peri-operative chemotherapy (HR 4, P=0.02), nodal involvement (HR 13, P=0.02) and pathological stage >T3 (HR 5, P=0.002) were risk factors for retention.
Conclusions: Our data suggests that female organ-sparing techniques may offer improved functional outcomes in women undergoing neobladder creation at cystectomy. Day and night continence appear to improve over time, regardless of the surgical technique.
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