University Hospitals Urologic Oncologist Performs Rare Female Neobladder Procedure

Organ-sparing surgery leads to improved quality of life for patient

Innovations in Cancer | Fall 2023

Since the 1970s, surgery for women with bladder cancer has typically meant removal of the bladder, uterus, cervix, fallopian tubes, ovaries and the anterior wall of the vagina. However, according to University Hospitals Seidman Cancer Center urologic oncologist Adam Calaway, MD, MPH, over the past 10 years, earlier detection of the cancer, better imaging, improved therapeutics prior to surgery and a growing recognition of the risks posed by removing organs has led to a shift in mindset.

Adam Calaway, MD, MPH

“We’re trying to reduce our scope,” he says. “We’re trying to minimize our surgical footprint, especially in females.”

Plus, he says, the risk of the bladder cancer invading the gynecological organs is less than 7 percent – and patients for whom the risk is higher can be relatively easily identified.

“Why would we remove things, if not invaded, from an oncologic standpoint?” he says. “By removing normal organs, we can significantly impact quality of life post-operatively without adding oncologic benefit. We're trying to challenge the long-standing dogma and appropriately select patients, especially female patients, for whom we can minimize the standard scope of surgery.”

Dr. Calaway had a recent case that put him at the center of this quality improvement trend. His 44-year-old female patient had a bladder cancer that required surgical removal of the bladder. Because of a combination of factors, she was a good candidate for an organ- and vaginal-sparing bladder removal.

“In her situation, her uterus was already removed, so we didn't spare that,” he says. “But we spared the entire vagina and the nerves around the bladder and the vagina. This allowed her to maintain her vaginal length to allow for comfortable penetrative intercourse. At the same time, saving the nerves around the vagina allowed for better sexual stimulation, sensation and lubrication. Those same nerves travel along the urethra, which obviously was spared.”

Sparing the patient’s ovaries was also of paramount importance given her age, Dr. Calaway says.

“Arguments can be made about sparing ovaries in postmenopausal patients, but still there is some low level hormonal production,” he says. “Sparing the ovaries is exceedingly important in patients who are that are premenopausal, such as this patient.”

Dr. Calaway also rebuilt the patient’s bladder with a neobladder made of intestines and reconnected to the kidneys and urethra – a surgical technique not commonly performed in women, even at high-volume institutions.

“No institution has more than maybe a hundred or so female neobladders even over decades,” he says. “The reasons are anatomical. We always used to take the anterior vagina and sometimes the urethra when we were doing a cystectomy. Without a urethra, a neobladder is unable to be created.  Even if you spare the urethra but take the anterior vagina, neobladders are rarely done due to concerns for fistula due to overlapping suture lines so you almost have to pick a patient for whom you can spare the vagina.”

Dr. Calaway says he hopes his urologic oncology colleagues across the country will continue the journey toward more organ-sparing surgeries like this one at UH Seidman.

“Sometimes we can't do this,” he says. “Careful patient selection is key to maximize the oncologic benefit of the surgery while minimizing the collateral damage. For certain females with bulky cancers, cancers near where the bladder meets the urethra, an area called trigone, or if it's near the urethra, sometimes leaving these things behind is not a very good idea, because it increases the risk of leaving cancer behind. And this disease is lethal. At the same time, we have the ability to potentially offer all sorts of urinary diversions and counsel patients on the pros and the cons of each.”

“Traditionally, even the most trained urologic oncologists don’t really do female neobladders because of the issues with it, including fistula formation, urinary leakage or hyper-continence,” he adds. “I think we have to be more open to it, because we're getting smarter and smarter all the time. We should know the patient and their disease so that we can make educated decisions, whether male or female, on certain surgical approaches, so we can maybe decrease our scope and maximize patients’ post-operative quality of life.”

Contributing Expert:
Adam Calaway, MD, MPH
Co-Director, Robotic Surgery
UH Cleveland Medical Center
Urologic Oncologist
UH Seidman Cancer Center
Assistant Professor of Urology
Case Western Reserve University School of Medicine