Rationale for bladder-sparing surgery in patients with locally advanced colorectal carcinoma

BACKGROUND. Total pelvic exenteration (TPE) with urinary diversion is a standard surgical approach for patients with locally advanced rectal carcinoma. Because only approximately 50% of patients undergoing TPE have tumor involving the bladder, the authors evaluated the feasibility of bladder salvage in this setting. The current study presents the results of a retrospective study of patients with advanced colorectal carcinoma (classification of ≥ T3) to formulate criteria for selecting patients for bladder-sparing procedures. METHODS. The charts of 81 patients with rectal carcinoma classified as ≥ T3 were reviewed for age, gender, computed tomography (CT) findings, results of intraoperative examination under anesthesia, final pathologic evaluation, urologic complications, local recurrence, and patient survival. RESULTS. Among the 46 patients who underwent TPE, final pathologic evaluation demonstrated tumor involvement of the bladder in 58% of patients. Preoperative identification of a bladder mucosal abnormality accurately predicted bladder involvement in only 57% of the 30 patients who underwent cystoscopy. CT and intraoperative palpation of the bladder individually predicted the final pathologic findings in 69% and 70% of patients, respectively; of the 21 patients in whom both were positive, 90% had bladder involvement. Of the 35 patients (26 females and 9 males) who underwent bladder-sparing procedures, 22 had complete sparing of the bladder, 9 underwent partial cystectomy (5 with ureteroneocystostomy), 4 underwent ureteroneocystostomy alone, and 2 underwent prostatectomy alone. Ninety-four percent of these 35 patients had negative histologic margins. There was no difference in the incidence rate of urinary complications between patients who underwent TPE and those who underwent a bladder-sparing surgery (17% each). The incidence rates of local recurrence (14% vs. 17%) and the 3-year survival rates (49% vs. 39%) did not differ significantly between the 2 groups. CONCLUSIONS. Bladder-sparing surgery to treat patients with locally invasive colorectal carcinoma provides good local control without sacrificing survival. Women, whose reproductive organs act as a natural barrier, and selected men in whom CT and intraoperative evaluation identify only localized involvement of the prostate or bladder appear to be reasonable candidates for bladder-sparing procedures.