Systematic review of the oncological and functional outcomes of pelvic organ-preserving cystectomy compared with standard radical cystectomy in women who undergo curative surgery and orthotopic neobladder substitution for bladder cancer

Context: Pelvic-organ preserving radical cystectomy (POPRC) for female patients may improve postoperative sexual and urinary functions without compromising the oncological outcome compared with standard radical cystectomy (RC).
Objective: To determine the effect of POPRC on sexual, oncological and urinary outcomes compared with RC in women who undergo standard curative surgery and orthotopic neobladder substitution for bladder cancer (BCa).
Evidence acquisition: Medline, Embase, Cochrane controlled trials databases and clinicaltrial.gov were systematically searched for all relevant publications. Women with bladder cancer who underwent POPRC or standard radical cystectomy and orthotopic neobladder substitution with curative intent were included. Prospective and retrospective comparative studies and single-arm case series were included. The primary outcomes were sexual function at 6-12 months after surgery and oncological outcomes including disease recurrence and overall survival at >2 years. Secondary outcomes included urinary continence at 6-12 months. Risk of bias assessment was performed using standard Cochrane review methodology including additional domains based on confounder assessment.
Evidence synthesis: The searches yielded 11,941 discrete articles, of which 15 articles reporting on 15 studies recruiting a total of 874 patients were eligible for inclusion. Three papers had a matched-pair study design and the rest of the studies were mainly small, retrospective case series. Sexual outcomes were reported in seven studies with 167/194 patients (86 %) having resumed sexual activity within 6 months post-operatively, with median patients’ sexual satisfaction scores 88.5 % ranging from 80% to 100%. Survival outcomes were reported in 7 studies on 197 patients, with a mean follow-up of between 12 and 132 months. At 3 and 5 yr, cancer-specific survival (CSS) was 70-100% and overall survival (OS) 65-100 %. 11 studies reported continence outcomes. Overall daytime and nighttime continence was 58-100% and 42-100%, respectively. Overall self-catheterization rate was 9.5-78%. Due to poor reporting and large heterogeneity between studies, instead of subgroup-analysis, narrative synthesis was made. The overall risk of bias was high across all studies.
Conclusion: For well-selected patients, POPRC with orthotopic neobladder may potentially be comparable to standard RC in terms of oncological outcomes whilst improving sexual and urinary function outcomes. However, in women undergoing cystectomy, oncological and functional data regarding POPRC remain immature and require further evaluation in a prospective comparative setting.