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Neobladder

Basic principles of neobladder construction:

  • Competent external rhabdosphincter
  • Detubularisation and reconstruction of bowel segment to ensure sufficient compliance and maintenance of low pressure during filling
  • Adequate storage volume once matured

Patient selection:

Patient factors

 

 Disease factors
Motivated and compliant, good dexterity

eGFR > 40 – 50

No liver dysfunction

No urethral disease

No previous pelvic radiotherapy

Adequate gut length / no IBD

No prolapse/SUI in women

 

 Contraindicated in:

·       “any need for urethrectomy”

·       Positive urethral frozen section

·       Extensive CIS

·       Bladder neck disease

·       Prostatic urethral disease

·       Locally invasive disease at vagina/cervix

 

Pre-operatively:

  • Optimisation of any co-morbidities and assessment of renal and liver function
  • Exclusion of bladder neck or urethral disease at TURBT
  • Willing and able to self catheterise
  • Bowel prep and rehydration preoperatively
  • Group and hold
  • Pelvic physiotherapy
  • Counselled for and sited for ileal conduit in case neobladder not able to be done

 

Technique:

  • Supine with break
  • Nerve sparing preferred during cystoprostatectomy and leave urethral length, don’t forget frozen sections
  • Identify 55 – 60 cm of ileum to be harvested and mark. Should be > 20 cm from TI. Make sure most dependent part of this bowel can reach pelvis and pubic bone (can mark this point with suture)
  • Divide mesentery at chosen locations (diathermy and ligasure) – distal mesenteric division should be deep and proximal division rather shallow to preserve supply – ideally 2 arcades
  • Restore bowel continuity (side to side stapled anastomosis a la conduit – corners cut off and antimesenteric staple)
  • Irrigate and wash isolated bowel segment

 

Studer:

  • Proximal 10 cm used as afferent limb – Bricker ureteric anastomosis over JJ stents
  • Remaining segment detubularised on antimesenteric border
  • Folded into U shape and medial edges sutured together with PDS, then bottom of the U folded up to create spherical neobladder (“double fold”)
  • Before closing, use finger to identify most dependent part and create 1 cm opening for urethrovesical anastomosis
  • Close spherical neobladder with sutures
  • Urethrovesical anastosmosis with interrupted sutures over 18 Fr IDC
  • SPC

 

Hautmann W:

  • Mark intended urethrovesical anastomosis site (most dependent) with suture when harvesting 60 cm
  • Dutubularise segment on antimesenteric border except for 3 cm at each end for chimneys, and the intended urethral site (open close to mesenteric border here)
  • Arrange into “W” shape with stay sutures
  • Suture the cut edges to create an ileal plate, with the chimneys preserved at the tips of the W (occasional locking sutures)
  • Ureteric anastomoses – spatulate ureter and do Wallace type anastomosis onto each chimney over a stent
  • Make a full thickness enterotomy in the dependent part intended for UV anastomosis – complete a la radical prostatectomy over 20 fr IDC with interrupted sutures – wider on neobladder to try and create a funnel type shape
  • Closure of the anterior neobladder
  • SPC

 

Neobladder can’t reach urethra:

  • Loosen retractors
  • Unbreak table
  • Free up the caecum and right colon
  • Relaxing incisions in mesentery / deepen mesenteric incision
  • Tubularisation or ‘chimney’ of dependent flap

 

Post-op:

  • Flushing of catheters regularly to ensure neobladder drained and catheters not obstructed by mucus or clot
  • Stents out around 2 weeks
  • Cystogram around 3 weeks via urethral IDC before removal
  • Timed voiding – initially every 1 – 2 hours including overnight – gradually increasing capacity aiming for 400 – 500 mL and then lifelong 4 hour timed voiding (or ISC)

 

Complications

Early

  • Infection
    • Pyelonephritis and UTI common in early post-operative period
  • Leak
    • Ureteroileal anastomoses x 2, bowel anastomosis, urethrovesical anastomosis, neobladder sutures
  • Ileus / SBO
  • Bleeding

Late

  • Metabolic acidosis (hyperchloraemic hypokalaemic)
    • May be best managed with sodium bicarbonate regularly
  • Incontinence
    • Women tend to be continent or hypercontinent and more likely to have higher residual volumes and need ISC
    • Men may have more nighttime incontinence (20 – 50 %), overall daytime incontinence about 10 %
  • Urethral complications
    • Urethral stricture or VUAS
    • Urethral recurrence
  • Ureteroileal strictures
  • Stones in neobladder (mucus, stasis, infection, metabolic acidosis, foreign body suture lines)
  • Neobladder rupture from overdistension
  • Chronic infections and pyelonephritis
  • Fistulae
    • Neobladder-vaginal
    • Enteric-neobladder / enterocutaneous
  • Other metabolic complications of ileal diversion
    • B12 deficiency, bone loss, bile salt malabsorption, stones, ammonia reabsorption.