Pregnancy after sexuality preserving cystectomy with urinary diversion for bladder cancer: case report and review of the literature

In 1922, Knauf firstly described pregnancy after urinary diversion [9]. Since then, the possibility to achieve pregnancy after bladder surgery for benign conditions in patients with urinary diversion, has been extensively reported. In a literature review by Hautmann et al., published in 2007, 252 cases of pregnancy in 188 women after UD were reported [9]. Among this population, authors described only two cases in which RC and UD (Ureterosigmoidostomy and Indiana pouch) for malignant disease had been performed [10, 11] suggesting that, despite the improvement of medical advances, a fertility-sparing approach was a viable option in a selected amount of patients. In the same year, Dhar et al. firstly described the feasibility of SPC with orthotopic diversion in women affected by localized BC, emphasizing functional advantages deriving from this approach [12]. However, pregnancy and delivery in patients with orthotopic neobladder after malignancy was not described until 2011, when Nunnink et al. reported the first case [13], (Table 1).

Table 1 Literature review with oncologic and gynecologic findings of pregnancy in women with history of sexuality preserving cystectomy for bladder cancer

Regarding surgical approach, open surgery was performed at the time of cystectomy in all cases described; to our knowledge, our experience represents the first one in which minimally invasive SPC (robot-assisted) was performed.

When histopathological findings after radical cystectomy are considered, urachal carcinoma, rabdomyosarcoma and urothelial cancer have been reported [10, 11, 13], with T-stage T2-T3b and absence of lymph node involvement [13, 14] in all cases.

During pregnancies after urinary diversion, displacement of neobladder (laterally to the right or left side) was observed [14], due to growing uterus. Most common conditions described are related mainly to neobladder emptying and ureteral compression, events that usually occurred during second trimester [14]. Management of hypercontinence usually consisted in starting or intensifying CIC. Sometimes, a placement of indwelling bladder catheter is required. Ureterohydronephrosis due to ureteral compression and recurrent urinary tract infections are the most frequent complications reported [13, 14]. Scheduled genitourinary US and urinalysis (at least once a month) were suggested [14], although management of asymptomatic bacteriuria was not assessed. When secondary pyelonephritis was suspected, intravenous antibiotics infusion and nephrostomy tube insertion have been performed [13, 14].

Bowel movement abnormalities due to adhesions and altered anatomy and metabolic complications are also reported [9].

Regarding delivery, both vaginal and caesarian section have been reported. In our patient, similar to Kolodizej experience, caesarian section was performed with incision in higher uterine segment in order to reduce the risk of neobladder or ureteral injury. The possibility of temporarily interrupting the flow of the internal iliac arteries with balloon catheters has also been described [14].

It has been reported necessity to continue CIC and/or to maintain bladder catheter and nephrostomy tube until uterus involution. We opted to perform antegrade pyelography, 5 weeks after delivery, before proceeding to nephrostomy tubes removal.

With the spread of sexuality preserving techniques and minimally-invasive surgery, the number of pregnancies and deliveries in patients with history of radical cystectomy and urinary diversion is expected to increase. Despite the number of possible complications, management of this particular setting of patients, that require close surveillance, is possible by relying on a multidisciplinary team, including urologists, gynecologists and neonatologists.

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