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.