Sexuality Preserving Cystectomy and Neobladder (SPCN): Functional Results of a Neobladder Anastomosed to the Prostate

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1 European Urology European Urology 43 (2003) Sexuality Preserving Cystectomy and Neobladder (SPCN): Functional Results of a Neobladder Anastomosed to the Prostate W. Meinhardt *, S. Horenblas Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands Accepted 3 March 2003 Abstract Objectives: In order to preserve the sexual functions in patients in need of a cystectomy, a feasibility study has been performed. Methods: In 24 male patients the seminal vesicles and the prostate were left in situ and a Studer type neobladder was anastomosed to the lateral edge of the prostate. Results: Storage and voiding strongly resembled the patterns reported in neobladder patients with the anastomosis directly to the urethra. Four of the 24 males needed to perform clean intermittent catheterisation (CIC). All but one patients had daytime continence. Three patients needed a pad at night. Five patients had erectile dysfunction, of whom two responded well to sildenafil treatment, one had good rigiscan 1 measured nightly erectile function and one had poor erections prior to the operation. Half of the patients had antegrade ejaculation, two patients reported sometimes antegrade and sometimes retrograde ejaculation. Conclusion: This feasibility trial showed that in the majority of our patients the remaining prostate does not interfere with micturition and the sexual functions were preserved. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Cystectomy; Sexual function; Urodynamics; Preservation of sexual function; Prostate sparing; Bladder carcinoma; Neobladder 1.Introduction In an attempt to preserve the sexual functions in males and females undergoing cystectomy a feasibility study was started with the aim of anatomical reconstruction of the urogenital tract without compromising sexual functions or oncological results. The indications, the technical aspects of this operation and the oncological results of this so called sexuality preserving cystectomy and neobladder (SPCN), were reported in a previous paper on the first 10 males and 3 females [1]. Others have reported on prostate sparing cystectomy. One report on four patients describes a technique of an oblique incision of the prostate, leaving the seminal vesicals and the posterior aspect of the prostate intact, * Corresponding author. Tel. þ ; Fax: þ addresses: w.meinhardt@nki.nl, w.meinhardt@planet.nl (W. Meinhardt). but excising the anterior proximal prostate [2].Another report deals with eight patients in whom the prostate was resected transurethrally prior to the cystectomy [3]. In this paper, we assess the functional results of our first 24 male patients. The emphasis is on voiding pattern and sexual function. 2.Materials and methods The operation technique, the indications and the oncologic follow-up are described in our previous paper [1]. In short, patients in need of a cystectomy, but without urothelial carcinoma of the bladder neck or the prostatic urethra (sampled transurethrally) and after exclusion of prostate carcinoma (PSA and sextant biopsies), who wish to retain their sexual functions, are candidates. A pelvic lymphnode dissection is done and a cystectomy is performed, while the seminal vesicals, the ductus deferens and the prostate are left in situ. A Studertype neobladder is anastomosed to the lateral edge of the prostate. To avoid spill of urothelial cancer cells during the dissection of the bladder neck, 20 Gy external beam radiation was /03/$ see front matter # 2003 Elsevier Science B.V. All rights reserved. doi: /s (03)00099-x

2 W. Meinhardt, S. Horenblas / European Urology 43 (2003) Table 1 Patient characteristics, n ¼ 24 males Age Range (years) Mean ( years) 58 Clinical stage Tcis 4 T1G3 N0 M0 4 T2/3 N0 M0 7 T2/3 Nþ M0 5 (operation after MVAC chemotherapy) T4 N0 M0 1 (operation after MVAC chemotherapy) Recurrence after 2 radiotherapy Other 1 Daytime continence 23 Nighttime continence 21 Need to catheterize 4 given prior to the operation. (Except the two patients with a previous external beam radiation treatment and the six patients with upfront chemotherapie.) All but one patient had bladder carcinoma and all were candidates for a neobladder. None of the patients had tumor extending to the bladder neck, into the prostatic urethra or prostate carcinoma. They wished to retain their sexual function and were informed about the experimental nature of this procedure, that was authorized by the medical ethical committee. Patient characteristics are summarized in Table 1. Functional aspects were studied with questionnaires (IPSS and a symptom checklist for incontinence and sexual function), rigiscan 1 measurements and urodynamics prior to and 1 year after the procedure. Rigiscan 1 readings were judged as normal when at least two events occurred, one of which at least with 70% rigidity and 10 minute duration). In two patients with obvious obstruction preoperatively, an adenoma enucleation (Freyer type), was performed during the cystectomy. 3.Results From 1995 till June 2001 an SPCN was performed on 24 males. The IPSS score pre-operative showed mild Fig. 1. Urodynamic investigation of a patient who shows the typical neobladder contractions (arrow) and initiates voiding by relaxation on the height of such a contraction (double arrow), after which he starts a Valsalva maneuver. Pelvic floor relaxation is good.

3 648 W. Meinhardt, S. Horenblas / European Urology 43 (2003) scores (0 7) in half of the patients and moderate scores (8 19) in the other half. Post-operative this deteriorated, mainly because all patients need to strain, adding five points to the score. 20% report mild scores postoperative, 75% moderate scores and 5% severe (20 35). The bother score of the IPSS showed a slight improvement from mean 1.9 to mean 1.5. In two patients the preoperative urodynamics showed obvious obstruction, and an additional Freyer type adenoma enucleation was performed during the cystectomy. Two patients experienced a period of poor emptying of the bladder while they had an urinary tract infection, both could stop clean intermittent catheterisation (CIC) 1 week after antibiotic treatment. Four patients need to perform CIC, one patient started 9 months after the operation, the others 1, 2 and 2.5 years post-operative. As indications for CIC we used: residual urine volume of at least 150 cc, if this is accompanied with infection or nightly frequency or incontinence, otherwise residual urine upto 250 cc is accepted. The voiding patterns in our patients strongly resemble the patterns as described for ileal neobladders with the anastomosis directly to the urethra [4]. A minority starts with relaxation of the pelvic floor while a pressure rise occurs in the neobladder, see Fig. 1. The majority starts with a Valsalva s maneuver and all patients strain to completion of the micturition, see Fig. 2. All but one patient have daytime continence (see Fig. 3). Six patients have nycturia of two times or more, of whom three experience nighttime incontinence for which they use a pad. On urodynamic testing we stop filling at 500 cc. No problems with bladder capacity were seen, only three patients had a neobladder capacity below 500 cc: 280, 320 and 350 cc. Table 2 provides the data on sexual function. Five patients have problems with their erectile function, two of them respond well to sildenafil, another one has a good nightly rigiscan 1 in spite of his complaint and one had the dysfunction already before the operation. Fig. 2. Urodynamic investigation of a patient who shows the typical neobladder contractions and initiates voiding with a Valsalva maneuver (arrow). This is the most common type of micturition in our patient group.

4 W. Meinhardt, S. Horenblas / European Urology 43 (2003) Fig. 3. Urodynamic investigation of a patient who shows the typical neobladder contractions, who has some loss of urine on the height of the contraction (arrow) resulting in contracting the pelvic floor (double arrow). During voiding the relaxation of the pelvic floor is good. He is only continent with a rigid frequent voiding regime. Table 2 Sexual function, n ¼ 24 Erectile function Post-operative sexual active (20) With sildenafil 2 With intra-cavernous injections 1 Post-operative sexual inactive (4) Good rigiscan 1 2 Poor rigiscan 1, prior to operation 1 Refused rigiscan 1 post-operative 1 Ejaculation (20 patients) Antegrade 10 Retrograde 8 Varying 2 The wish to remain sexually active is one of the inclusion criteria. However (probably due to the polychemotherapy), one patient was not active prior to the operation. Post-operative 20 patients restarted sexual activity. Half of the patients report antegrade ejaculations, two report this differently from time to time. 4.Discussion While the IPPS score became higher post-operative, the bother score showed a slight improvement. This most likely indicates that after major surgery patients tend to accept their complaints (response shift bias). The question needs to be answered if the prostate interferes with evacuation of the neobladder, since this is a low pressure system without the usual detrusor contraction on voiding. Mikuma has studied a group of 12 patients with a neobladder anastomosed to the urethra. Patients with a poor voiding pattern (flow rate <15 ml/s and straining on average seven times to

5 650 W. Meinhardt, S. Horenblas / European Urology 43 (2003) completion) showed the same vesical opening pressures and vesical pressures at maximum flow rate compared to patients with a fine voiding pattern (flow rate >15 ml/s and straining one or two times to completion). Obstruction was not the distinguishing factor [5]. This means that on the basis of the flow pattern we cannot decide if the prostate that was left in situ is obstructive. As noted by the ICS subcommittee on Intestinal Urinary Reservoirs great caution is needed when interpreting flow pressure studies in these patients with regard to the diagnosis of outlet obstruction [6]. Since all our patients strain to void, a pressure flow study will not provide unequivocal data. An evaluation of the possible obstructing role of a prostate in our patients with the neobladder anastomosed to the prostate should be based on the presence of residual urine with the need for catheterisation. Since four of the 24 patients needed CIC, it may be stated that the prostate causes no obstruction in the majority. However, 17% in need of CIC is higher than the rates reported by Studer et al. (2%) [7], Hautmann et al. (3.9%) [8] and Arai et al. (4.9%) [9]. Since we saw no strictures of the anastomosis to the prostate we feel that there is no need to resect the anterior part of the prostate as has been proposed in the past [2]. Continence rates are favorable with 96% daytime continence, compared to the above-named authors: 92%, 95.1%, 95.1%, respectively. Sexual function is indeed preserved, erections and even antegrade ejaculation. Considering that six patients had received MVAC polychemotherapy and two patients had a salvage cystectomy we consider this a good result. Only one of the five patients with complaints about the erections had the combination of a good rigiscan 1 before and a poor rigiscan 1 after the operation and no response to sildenafil. In this patient the operation may have caused major damage to the nerves or the blood vessels of the penis. In 50% of the patients ejaculation was antegrade and some reported periods of antegrade as well as periods of retrograde ejaculation. Since we excised the bladder neck and our anastomosis is to the lateral margin of the prostate, the prostate itself must play an important role in antegrade ejaculation. This finding is confirmed by Skinner and co-workers who reported three out of four patients with antegrade ejaculation [2]. 5.Conclusion In this feasibility trial of the SPCN in 24 male patients, it is shown that for the majority of our patients the prostate, that is left in situ, does not interfere with micturition and the sexual functions are preserved. In order to assess the oncological soundness of this approach a larger, multi-center trial is launched. References [1] Horenblas S, Meinhardt W, IJzerman W, Moonen FM. Sexuality preserving cystectomy and neobladder: initial results. J Urol 2001;166: [2] Spitz A, Stein JP, Lieskovsky G, Skinner DG. Orthotopic urinary diversion with preservation of erectile and ejaculatory function in men requiring radical cystectomy for nonurothelial malignancy: a new technique. J Urol 1999;161: [3] Colombo R, Bertini R, Salonia A, Filippo da Pozzo L, Montorsi F, Brausi M, et al. Nerve and seminal sparing radical cystectomy with orthotopic urinary diversion for selected patients with superficial bladder cancer: an innovative surgical approach. J Urol 2001;165:51 5. [4] Koraitim MM, Atta MA, Foda MK. Desire to void and force of micturition in patients with intestinal neobladders. J Urol 1996;155: [5] Mikuma N, Hirose T, Yokoo A, Tsukamoto T. Voiding dysfunction in ileal neobladder. J Urol 1997;158: [6] Thüroff JW, Mattiasson A, Andersen JT, Hedlund H, Hinman Jr F, Hohenfellner M, et al. The standardization of terminology and assessment of functional characteristics of intestinal urinary reservoirs. Br J Urol 1996;78: [7] Studer UE, Danuser H, Hochreiter W, Springer JP, Turner WH, Zingg EJ. Summary of 10 years experience with an ileal low-pressure bladder substitute combined with an afferent tubular isoperistaltic segment. World J Urol 1996;14: [8] Hautmann RE, de Petriconi R, Gottfried HG, Kleinschmidt K, Mattes R, Paiss T, et al. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999;161: [9] Arai Y, Taki Y, Kawase N, Terachi T, Kakehi Y, et al. Orthotopic ileal neobladder in male patients: functional outcomes in 66 cases. Int J Urology 1999;6: