Authors from Sao Paulo describe their experience with the orthotopic ileal neobladder in women. They describe it as currently being the urinary diversion of choice for women in their institution. They found it to be safe and associated with a high continence and low urinary retention rates.
To report our experience with orthotopic bladder reconstruction in women, as currently the ileal orthotopic neobladder is the diversion of choice for women requiring a bladder substitute at our institution.
PATIENTS AND METHODS
From February 1995 to March 2001, 29 women with muscle-invasive bladder carcinoma underwent a nerve-sparing radical cystectomy and had an orthotopic ileal neobladder reconstructed. The outcome was evaluated at 2 and 6 months and then yearly, by a clinical history, physical examination, voiding diary, stress test and estimate of functional neobladder capacity.
All patients were followed for at least 14 months (mean 27.5); there were no major complications related to the surgery. The mean (range) neobladder capacity 2 months after surgery was 250 (190–320) mL; at 6 months it increased, remaining stable for the remaining follow-up, at 450 (350–700) mL. Four patients (14%) had nocturnal incontinence and one stress urinary incontinence, associated with using three pads per day. Three patients (10%) required catheterization for a postvoid urinary residual of >100 mL. Of the 29 patients, seven died with metastatic disease and three from causes unrelated to the reservoir or bladder cancer. Currently, 19 patients (65%) are alive and disease-free, with a mean follow-up of 35 months.
Orthotopic neobladder reconstruction in women, using 40 cm of ileum, is safe and gives high continence and low urinary retention rates. Therefore, it should be advised as the first option in women with good renal function and a tumour-free bladder neck.
In 1979, Camey and Le Duc  described a bladder reconstruction technique which gave high urinary continence rates in men who had had a radical cystectomy, by creating an orthotopic neobladder from a bowel segment. The same orthotopic neobladder reconstruction was delayed in women because of concerns about urinary continence and urethral tumour recurrence. The first concern was lessened after neuro-anatomical studies of the female pelvis and urethra [2,3], and the second by pathological studies which defined those patients who had a low chance of tumour recurrence in the urethra [4,5]. At our institution we have been using an orthotopic ileal neobladder in women for lower urinary tract reconstruction since 1995; herein we report a mid-term follow-up of our experience using this technique.
PATIENTS AND METHODS
We retrospectively assessed 29 women with clinically localized bladder cancer who had a total cystectomy and ileal orthotopic neobladder constructed between February 1995 and March 2001. Exclusion criteria for neobladder reconstruction included direct invasion of cancer cells into the bladder neck, presence of urethral tumour and a serum creatinine level of 2 mg/L. The outcome was evaluated at 2 and 6 months and then yearly, by a clinical history, physical examination, voiding diary, stress test (with 300 mL in the reservoir), CT, IVU and retrograde cystography. The functional capacity was defined as the volume in the neobladder that generated a sensation of fullness or urethral leakage, and was evaluated by ultrasonography. We defined urinary incontinence as the use of more than one pad per day. Surgical complications and neobladder function were evaluated and described. The surgical procedure was the same in all patients and was performed by the same surgeon (L.J.N.) as described below.
The radical cystectomy was performed as previously described . Briefly, the urethra was isolated from the vaginal wall by making two small incisions on the endopelvic fascia, at bladder neck level. After isolating the urethra, it was incised just distally to the bladder neck and the bladder separated from the vagina toward the uterus. The lateral vascular bundles were incised close to the bladder to preserve the pelvic nerves located laterally to the vagina. Once the cystectomy was completed the orthotopic intestinal neobladder was created using 40 cm of distal ileum, which was isolated 20 cm proximal to the ileo-caecal valve. The ileal segment was opened longitudinally in the antimesenteric edge and rearranged in a ‘J’ shape . Both ureters were implanted in the longest limb of the J at the ileal plaque, using Le Duc's antireflux technique . The caudal extremity of the pouch was sutured to the urethra circumference using eight sutures of 3–0 polyglactin. Pigtail catheters were positioned bilaterally in the renal pelvis through the ureter and attached distally to a urethral 20 F Foley catheter. All catheters were removed after 21 days; after surgery patients were encouraged to urinate at 4 h intervals and once at night.
The mean (range) age of the women was 62 (42–77) years, and all had surgery as the first-line therapy for bladder cancer. The mean (range) duration of surgery was 5 (3.5–6) h, of hospitalization 8 (6–10) days and of drainage 7 (6–10) days, with the urethral and ureteric tubes being left for 21 days. After surgery, the histological study showed six patients had pT1 disease, 12 pT2a, nine pT2b and two pT3 and positive iliac lymph nodes. Overall, the mean follow-up was 37.5 (14–96) months. Of the 29 patients, seven died with metastatic disease and three from causes unrelated to the reservoir or bladder cancer. Currently, 19 patients (65%) are alive and disease-free, with a mean follow-up of 35 months.
The mean neobladder capacity 2 and 6 months after surgery was 250 (190–320) and 450 (350–700) mL, respectively. The increase in reservoir capacity remained stable during the remaining follow-up. Four patients (14%) had nocturnal incontinence and used pads while sleeping; one also had diurnal stress urinary incontinence, using three pads per day. Three patients (10%) required urethral catheterization because they had a postvoid residual of >100 mL. The early and late complications after surgery are shown in Table 1.
|Abdominal wall infection||0|
|Prolonged ileum||5 (23)|
|Dehiscence of intestinal suture||0|
|Intermittent catheterization||3 (10)|
|Unilateral hydronephrosis||3 (10)|
|Pelvic recurrence + abdominal wall metastasis||1 (3)|
|Visceral metastasis||6 (21)|
|Death from cancer progression||7 (24)|
The orthotopic reservoir created using 40 cm of ileal segment in women caused minimum complications and gave high continence rates. The results confirmed the safety of the procedure not only for patients with bladder cancer, but also for those requiring lower urinary tract reconstruction.
It was >10 years before the orthotopic neobladder described by Camey and Le Duc  was applied in women, because of concerns about urinary incontinence . The use of the orthotopic neobladder avoids the inconvenience of incontinent abdominal stomas or intestinal diversion, and decreases the incidence of metabolic disturbances, UTIs and kidney atrophy, improving the quality of life of patients after cystectomy.
The urinary continence of patients with a neobladder depends on a low-pressure reservoir, preserved striated sphincter and the remaining intrinsic urethral sphincter, while voiding is by a Valsalva manoeuvre associated with pelvic floor and sphincter relaxation. A fetal neuroanatomical study of the female urethra and pelvis  showed that smooth muscle innervation in the bladder neck and proximal third of the urethra is through the pelvic plexus located lateral to the vagina and bladder neck. In the mid and distal urethra the striated musculature is innervated by branches of the pudendal nerve. That study concluded that preserving two-thirds of the distal urethra and its innervation should be enough to maintain continence in women after cystectomy .
The better understanding of the physiology and pelvic anatomy of the pouch, and improvements in surgical techniques and postoperative care, are the main reasons for the success of the continent reservoir. Several studies showed that reservoirs created using detubularized intestinal segments have a greater capacity with low intraluminal pressure, which increases continence and the upper urinary tract preservation rate [10–12].
The reservoir capacity is an essential aspect; it may lead to incontinence if excessively small, or retention if excessively large. A reservoir using 40 cm of ileal segment gives a higher incidence of daytime and night-time incontinence than larger pouches (using 60–65 cm of ileal segment) in the first 6 months  but after 1 year the nocturnal and diurnal urinary continence rates become similar, although larger reservoirs have a higher incidence of significant postvoid urinary residual and functional neobladder decompensation . This might be explained by the present findings showing that the neobladder has a limited increase in reservoir storage capacity within the first 6 months. Thus, using 40 cm of ileum to create a neobladder in women generates a good capacity pouch, with low leakage and retention rates, allowing satisfactory emptying by Valsalva manoeuvre and relaxing the sphincter. Stein et al. followed 34 women after cystectomy and a neobladder created by a Kock pouch, reporting diurnal and nocturnal continence rates of 88% and 82%, respectively; 15% of the patients required intermittent catheterization. Bejany and Politano  reported five patients with interstitial cystitis treated with cystectomy and neobladder reconstruction using an ileo-colonic segment. During the follow-up, all patients became dry and two needed self-catheterization. Cancrini et al. reported that of seven patients, all had complete diurnal continence and five nocturnal continence after having an ileal neobladder using Studer's technique. In the present study, of the 29 patients, one had diurnal stress incontinence (97% continent), three nocturnal incontinence, using pads to sleep (90% nocturnal continence) and three needed intermittent catheterization. For the upper urinary tract, three women (10%) had unilateral hydronephrosis, all managed conservatively with no compromise of kidney function.
The most frequent indication for orthotopic neobladder reconstruction has been radical cystectomy in patients with infiltrating bladder cancer. All patients who are not candidates for urethrectomy are potential candidates for neobladder orthotopic reconstruction. Patients with no bladder-neck disease have a lower incidence (2%) of urethral recurrence than patients with tumour at the bladder neck (13%) . Therefore, in the latter patients orthotopic reconstruction would not be the best choice. Another important consideration is renal function; we do not create a neobladder in patients with a serum creatinine of >2 mg/L because of the risks of metabolic disturbance.
In conclusion, in this mid-term follow-up of 29 women after cystectomy and orthotopic neobladder reconstruction with 40 cm of ileum, the procedure was safe and gave high continence and low urinary retention rates. Therefore, it should be recommended as the first option for women with good renal function and a bladder neck free of tumour.
CONFLICT OF INTEREST