How are orthotopic neobladders constructed during a radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
  • Print
Answer

Orthotopic neobladders are constructed in the anatomic position and anastomosed to the native urethra. Volitional voiding is achieved by increasing the abdominal pressure and relaxing the external sphincter. The neobladders can be fashioned from ileum, ileocolonic tissue, or sigmoid colon. During dissection, special attention must be given to protect the urethra, periurethral musculature, and sphincter. Complications include daytime incontinence (approximately 10% of patients), nocturnal incontinence (20%-30%), hypercontinence requiring catheterization (approximately 20% in women), urinary retention (10%, due to obstruction caused by stricture, residual prostate tissue, disease recurrence, or mechanical kinking of the urethra or neobladder dysfunction), and, rarely, ureterointestinal anastomotic stenosis or fistula formation.

Numerous variations of the orthotopic neobladder have been introduced, but the Studer-type pouch, because of its versatility, is currently used most often. The pouch is particularly useful with short ureters because the proximal limb can be configured to reach cephalad, if necessary. A 50- to 60-cm ileal segment is isolated approximately 15-20 cm proximally to the ileocecal valve. The distal 40-45 cm are detubularized, folded, and fashioned into a pouch with 2-0 absorbable sutures. The ureteroileal anastomoses are placed in the unopened, isoperistaltic afferent segment. A small opening is placed in a dependent portion of the pouch and anastomosed to the urethral stump with interrupted absorbable sutures.

Other neobladders include the Camey, a 60-cm segment of ileum fashioned into a U shape; the Hautmann, which is similar to other neobladders, but W-shaped to increase capacity; and the Mainz, LeBag, and UCLA pouches, which all use ileocecal segments.

Table 2. Advantages and Disadvantages of Intestinal Segments Used for Urinary Diversion (Open Table in a new window)

Segment

Advantages

Disadvantages

Stomach

Can be used in patients with renal failure, hepatic failure, acidosis, and pelvic radiation; no mucus production

Hypokalemic hypochloremic metabolic alkalosis, hematuria dysuria syndrome due to acid irritation of the urothelium, concern for increased secondary malignancy

Jejunum

N/A

Hyperkalemic hypochloremic metabolic acidosis, hyponatremia, osteomalacia (Avoid if at all possible.)

Ileum

Familiarity to urologists

Hypokalemic hyperchloremic metabolic acidosis, vitamin B-12 deficiency, fat malabsorption, diarrhea, osteomalacia (not a good option following pelvic radiation)

Colon

Transverse colon can be used in patients who have had pelvic radiation.

Hypokalemic hyperchloremic metabolic acidosis, osteomalacia; most mucus production of all intestinal segments


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!