Pathological Guidelines for Orthotopic Urinary Diversion in Women with Bladder Cancer: a Review of the Literature

Purpose: Before the early 1990s total urethrectomy at radical cystectomy for bladder cancer in women was considered the standard of care. As our understanding of the natural history of urethral urothelial carcinoma in women has improved, neobladders have been increasingly created in carefully selected women with bladder cancer. We reviewed the literature regarding the incidence of urethral involvement, the risk factors for urethral involvement and the incidence of urethral recurrence in women undergoing orthotopic urinary diversion for bladder cancer.

Materials And Methods: A comprehensive literature review was performed regarding the natural history of urethral tumor involvement by urothelial carcinoma, risk factors and the incidence of urethral recurrence following radical cystectomy and orthotopic diversion in women with bladder cancer.

Results: Urethral tumor involvement occurs in approximately 12% of female patients with bladder cancer undergoing radical cystectomy for high grade, invasive urothelial carcinoma. Preoperative involvement of the bladder neck or anterior vaginal wall with urothelial carcinoma is an important risk factor for urethral tumor involvement. Intraoperative frozen section analysis of the proximal urethra is an appropriate and reliable method of identifying female candidates for orthotopic diversion. The rate of secondary tumor recurrence in the retained urethra of women following radical cystectomy and orthotopic urinary diversion is low but the condition requires long-term followup.

Conclusions: Orthotopic urinary diversion can be performed safely in appropriately selected women with bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence. Preoperative bladder neck involvement is an important risk factor for urethral involvement but not an absolute contraindication to orthotopic diversion should intraoperative frozen section of the proximal urethra be without evidence of malignancy.