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Sexual function in men after radical cystoprostatectomy differs in men with ileal conduit compared to orthotropic neobladder urinary diversion
Charlotte Q. Wu, MD, Stanton Honig, MD, Thomas V. Martin, MD, David G. Hesse, MD.
Yale New Haven Hospital, New Haven, CT, USA.

BACKGROUND: Men with invasive bladder cancer requiring cystoprostatectomy may choose an orthotopic neobladder (ON) because of self image issues. Self image issues are intimately associated with sexual function. Choosing an ON must be weighed against the increased exposure to complications from complex surgery, and a realization that high-grade bladder cancer is associated with high morbidity and mortality. Are we really helping men by advising them to consider ON if post-op sexual function in these men is unrealistic? METHODS: 72 men from 2007 to 2016 treated with cystoprostatectomy or total exenteration for bladder cancer were identified. 50 men chose ileal conduit or colon conduit urinary diversion (IC). 22 men chose ON. Post-op complications and overall survival in both groups were retrospectively reviewed. Follow up analysis of sexual functioning in both groups was based on 1) whether interest in treatment for erectile dysfunction (ED) was described in clinic notes, 2) whether a prescription for PDE5 inhibitor medication had ever been prescribed, and 3) whether treatment was ever sought in a referral ED clinic at our institution.
RESULTS: Mean follow up time was 49 months (range 6 to 121 months) for IC patients. Mean follow up time was 18 months (range 4 to 110 months) for ON patients. 38% of IC patients had a complication following surgery (12 Clavien-Dindo grade I, II; 5 grade IIIb; 2 grade IVa). 50% of ON patients had a complication following surgery (2 Clavien-Dindo grade II; 1 grade IIIa; 5 grade IIIb; 1 grade IVa; 2 grade V). 1/50 men in IC group expressed interest in ED treatment postoperatively (2%). 3/13 men in ON group were sexually active with spontaneous erections (with or without PDE5 inhibitors). 5/13 men in ON group sought care at ED clinic and were sexually active using either vacuum device, penile injection therapy, or following penile implant. 61% of men in ON group were sexually active
CONCLUSIONS: Invasive bladder cancer has a high mortality. Cystoprostatectomy and urinary diversion can be associated with significant complications. These complications are increased in ON compared to IC urinary diversion groups. Sexual function appears to be important to men choosing ON. Men undergoing orthotopic neobladder urinary diversion are more likely to proceed with treatment options for sexual function then men undergoing ileal conduit urinary diversion.

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