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Abstract
Urinary diversion is an essential component of the surgical procedure after cystectomy. Replacement with an
orthotopic ileal neobladder should be the first choice if external urethral sphincter sparing surgery is possible,
offering good long-term function, quality of life and patients acceptance with few complications.
The possible use of a variety of alternative intestinal segments widen the horizon of the reconstructive surgeon,
allowing him or her to be prepared for unusual cases.
Contraindications for orthotopic neobladder reconstruction include tumour location, reduced renal, liver,
intestinal function, intellectual ability and physical handicaps.
It is therefore important to custom tailor the appropriate mode of diversion for individual patients with a variety of
options available, including ureterocutaneous stomas, intestinal conduits and continent catheterizable reservoirs and
orthotopic neobladders. All these techniques require detailed knowledge of the possible metabolic problems
encountered by using gastrointestinal segments and how they react in contact with urine. Modern surgical
techniques such as nerve sparing surgery have the ability to preserve postoperative continence with voluntarily
micturition as well as sexual function. In addition, preliminary experimental data hold great promise that the off
shelf bladder substitute may become a technique of choice in the future, avoiding common problems encountered
using current technqiues.
# 2005 Elsevier B.V. All rights reserved.
Keywords: Urinary diversion; Bladder substitute; Conduit; Neobladder; Continent catheterizable reservoir
1. History
In 1852, Simon first reported a urinary diversion
using intestinal segments [26]. In 1888, the first orthotopic diversion in an animal study was performed by
Tizzoni and Foggi [39]. Coffey introduced uretreosigmoidostomy in 1911, which became the standard technique, although the ileal conduit was reported by Zaayer
in the same year [22]. It took another 40 years, in which
many patients died because of hyperchloremic acidosis
(suffered by 80% of all patients with ureterosigmoidostomy) until Bricker established the ileal conduit as a
diversion of first choice in 1950 [5].
* Corresponding author. Tel. +49 7071 2986615;
Fax: +49 7071 2985092.
E-mail address: Udo.Nagele@med.uni-tuebingen.de (U. Nagele).
1570-9124/$ see front matter # 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.euus.2005.07.003
130
131
132
Table 1
General contraindications to continent urinary diversions
1.
2.
3.
4.
5.
6.
From the oncological standpoint there are no significant differences in cancer-specific survival between
ileal conduits and contemporary bladder substitutes
[42]. The low local tumor recurrence rate of 11%
and the recurrence rate of 25% in the urethra support
the trend towards orthotopic urinary diversion [13,18]
and demonstrate that safe patient selection for an
orthotopic neobladder is possible.
After decades of searching for the ideal gastrointestinal segment, many surgeons favour nowadays
the ileal neobladder, because of easy harvesting and
handling as well as low intraluminal pressures [15,36].
Approximately 40 cm of ileum are necessary to create
an adequate volume reservoir. Key points with every
neobladder are the connections cranially to the ureters
and caudally to the urethra.
5.3.1. Afferent anastomosis: Reflux prevention how
and when to do it
5.3.1.1. Technique of reflux prevention
5.3.1.2. Camey - Le Duc. A channel is created on the
posterior intestinal wall by incising the mucosa longitudinally for 33.5 cm all the way to the muscularis.
At the proximal end, the obliquely cut the ureter
penetrates into the lumen of the neobladder and is
fixed at the distal end of the channel. The Camey-Le
Duc ureteroileal anastomosis must be considered historical now. It has been widely abandoned due to its
high complication rate.
5.3.1.3. Intussusceptive ileal nipple.The Hemi-Kock
type of intussusceptive ileal nipple with both ureters
implanted at the proximal end of the nipple creates a
good intraluminal valve, but there is considerable risk
of long-term obstruction (Fig. 2).
5.3.1.4. Serosa-lined extramural tunnel implantation (Abol-Enein, Stein). After detubularization, the
ileum it is arranges as a W, M, or double-folded
133
134
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Table 2
Advantages of the orthotopic technique described
1.
2.
3.
4.
6. Conclusion
In the 21st century, in both male and female patients
with bladder cancer requiring cystectomy, an orthotopic bladder substitution should be the first choice of
urinary diversion whenever the urethra can be spared
safely, without compromising the oncological aim of
the procedure. Refinements of surgical techniques such
as autonomic nerve preservation and improved afferent
(ureteral) and efferent (urethral) anastomoses result in
excellent functional outcomes and improved quality of
life. Understanding the structural transformation of the
ileal mucosa and metabolic changes as well as the
functional principle of the neobladder results in a
structured follow-up, and avoids postoperative complications. Other types of continent and incontinent
urinary diversion remain valid and time-tested options,
whenever an orthotopic bladder replacement is not
possible. Using careful selection criteria, the type of
136
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CME questions
Please visit www.uroweb.org/updteseries to answer
these CME question on-line. The CME credits will
then be attributed automatically.
1. A catheterizable reservoir is not indicated:
A. if an external urethral sphincter sparing surgery
is not possible
B. in patients with urethral malformations
C. in the incompliant patient
D. in complex neurourological defects
2. Which of the following techniques of reflux prevention has been abandoned due to its high complication rates?
A. Camey-LeDuc
B. Intussusceptive ileal nipple
C. Serosa-lined extramural tunnel implatation
D. Isoperistaltic tubular limb