CONTINENCE RECOVERY IN PATIENTS UNDERGONE RADICAL CYSTECTOMY AND ILEAL ORTHOTOPIC NEOBLADDER

Objective

Radical cystectomy plus ileal orthotopic bladder substitution is a choice for primary invasive bladder cancer and for high grade, refractory to conservative therapy, multifocal and quickly recurrent superficial bladder cancer, in young patients determined to maintain an adequate self corporeal image. During radical cistoprostatectomy it is fundamental an anatomical preparation of urethral sphincter with an excellent visualization of prostatic apex. After that, urethra can be resected with the maximum respect of anatomical boundaries of urethral sphincter and minimizing the risk of leaving prostatic tissue in situ. The aim of our study is to investigate functionally and oncologically the role of verumontanum as a landmark for the complete saving of striated sphincter in patients undergone radical cystectomy and ileal orthotopic bladder substitution.

Methods and results

From January 2008 to December 2012 we prospectively collected the data of 63 patients undergone radical retropubic cystoprostatectomy plus ileal orthotopic bladder substitution for clinically localized bladder cancer. We compared the intraoperative identification and saving of verumontamum and follow-up data determined through urodynamic evaluation. Clinical, surgical and complete follow-up data were available in 55/63 patients. The urethral sphincteric mechanism was evaluated with urodynamic study in different positions at a minimum follow-up of 12 months. After that, to compare intraoperative findings every patient underwent uretrocystoscopy to confirm the presence or absence of verumontanum. Continence was evaluated with ICIQ-SF questionnaire at month 1, 3, 6 and 12. Mean follow-up was (range) 28.5 (12-52) months. In 6/55 (10.8%) cases it was found transitional cancer in bladder trigone. In two cases it was discovered a pT2b prostatic carcinoma Gleason 3+3. None of the cases showed a positive apical surgical margin. Overall, 45/55 (81.8%) patients completely fulfilled our continence criteria (≤1 pad/die and ICIQ-SF≤2/2/2) in daytime and 36/55 (65.4%) on nighttime at a minimum follow-up of 12 months. In 22/55 (40%) patients with verumontanum (Group A)continence was obtained within the first month in 3/22 (13.6%) cases Vs 0/33 in patients without the saving of verumontanum (Group B), 7/22 (31.8%) Vs 7/33 (21.2%) within the third month,14/22 (63.6%) Vs 19/33 (57.6%) within the sixth month and in 19/22 (86.3%) Vs 24/33 (72.7%) at a12-months follow-up in Group A and B respectively. The saving of verumontanum resulted statistically significant in overall continence (p=0.0067) and influential in early recovery of continence (p<0.0001). Urodynamic evaluation demonstrated a
significantly longer functional urethral length in Group A patients (mean, range: 32, 28-37 mm) Vs Group B patients (25, 16-31 mm) (p=0.0036). Overall 19/22 patients of Group A demonstrated a Valsalva leak point pressure ≥40cmH2O Vs 24/33 of Group B.

Discussion

The recovery of continence in patients with orthotopic neobladder is a crucial functional outcome. Verumontanum can be considered an visual intraoperative landmark in saving the maximum of striated sphincter and, consequently, the maximum of striated sphincter through an anatomical preparation of prostatic apex. In our experience,the saving of verumontanum during radical cistectomy and ileal orthotopic bladder substitution improved overall and early continence recovery. The limit of this study is represented by the small number of both groups and the exiguity of events; our pilot study underlines the need of large, randomized trials to define the role of verumontanum in overall and early continence recovery