ORTHOTOPIC URINARY DIVERSION IN WOMEN

Reconstitution of a normal voiding pattern is the ultimate goal in constructing a urinary diversion after a radical cystectomy. An orthotopic neobladder is the current state-of-the-art urinary diversion. Although surgeons may believe that successful removal of the bladder is the most difficult part of a radical cystectomy and urinary diversion, to the patient the type of urinary diversion is the most important part of the surgery. After Bricker, 2 in 1950, introduced the ileal conduit as the gold standard in urinary diversion following a radical cystectomy, there was relatively little innovation over the next 20 years. The need for a bag to collect urine after a radical cystectomy may have led to a delay in treatment of patients with bladder cancer, particularly those with high-grade transitional-cell carcinoma invading the lamina propria. By constructing a urinary diversion that can better mimic the normal voiding pattern, the indications for radical cystectomy have been changing to include some patients with high-grade early-stage tumors. 4,9 With improvements in surgical technique and an understanding that the type of urinary diversion has a major impact on body image, lifestyle, and self-confidence, there has been an emphasis on constructing continent urinary diversions that allow patients to lead more normal lives. 1 In the 1970s and early 1980s, the Kock pouch was one of the first continent cutaneous urinary diversions to become widely used. 5,14 Numerous other continent cutaneous diversions then were introduced, including the Indiana pouch, which may have the widest acceptance and usage. 13 Continent cutaneous diversions incorporate the basic premise of a detubularized bowel segment and a catheterizable abdominal skin stoma. Unfortunately, catheterization of an external stoma is required and complications can occur in 10 to 20% of patients. 6,13 Orthotopic urinary diversions were first introduced by Camey in 1979. 8 Using a tubularized ileal segment anastomosed to the urethra, reasonable continence rates were obtained. With the increased expertise in pelvic surgery afforded by the rise in the number of radical prostatectomies performed by urologic surgeons, and a better anatomic understanding of the continence mechanism in men, interest in orthotopic diversions grew. Hautmann 19 described one of the first orthotopic diversions, which was a large detubularized ileal segment that was anastomosed to the urethra. Excellent daytime continence was reported, but nighttime incontinence occurred in up to 50% of patients. Orthotopic diversions initially were done exclusively in men. Only recently have orthotopic urinary diversions been considered in women, for multiple reasons, including the routine resection of the anterior vagina during a radical cystectomy in a woman, which could lead to a pouch–vaginal fistula if an orthotopic diversion was performed; routine resection of the urethra during a radical cystectomy; and a poor understanding of the continence mechanism in women. Anatomic dissections of the female pelvis, however, recently have been performed that better delineate the continence mechanism in women. 3 Consequently, it became clear that complete resection of the bladder while preserving the urethra and surrounding sphincter mechanism could be performed safely in women. Using many of the criteria for performing an orthotopic urinary diversion in men, most women undergoing a radical cystectomy are candidates for an orthotopic neobladder. The risk for incontinence or hypercontinence is similar between men and women. 18 In this article, the author discusses the following issues related to orthotopic urinary diversions in women: Preoperative selection parameters to ensure a good outcome, a detailed step-by-step description of our surgical technique, and key postoperative issues.