Sparing radical cystectomy - How much is enough?

Radical cystectomy in females is increasingly being followed by orthotopic urinary diversion. This is particularly true when it comes to young patients. Wisahi et al. [1] from Egypt describe a small series of such patients with Bilharziosis associated bladder cancer. The results presented match well with those presented in other series [2-4]. Nerve-sparing radical cystectomy has been shown to be the most important determinant for subsequent neobladder function and sexual quality of life. Preservation of the uterus as proposed herein allows for very extensive nerve sparing. Moreover, dorsal stability is provided for the neobladder, which is also considered helpful in preventing obstruction. However, even with this approach still 3 women require CIC in this group. One may argue that other unknown factors could also be influential. Neobladder type itself does not appear as important as the actual radical cystectomy. Several groups have shown this before [2-4]. More importantly the authors have shown excellent sexual function. In very young women even pregnancy may be feasible. Leaving the uterus behind nevertheless is a risk factor for any later instrumentation to the internal genitalia. Injury to the neobladder is inadvertent if no urologist is part of the surgery team in such cases [5]. Overall survival was excellent in this group of women with two-thirds of them living more than 10 years. Aggressive early surgery may thus be warranted even in very young women affected by invasive bladder cancer. In developing countries such as Egypt or India clinicians are frequently challenged with young bladder cancer patients requiring radical cystectomy. The article published in this issue of the journal is particularly relevant to them.