- Email: [email protected]
The “B-Bladder”—an Ileocolonic Neobladder with a Chimney: Surgical Technique and Long-Term Results
European Urology
European Urology 45 (2004) 794–798
The ‘‘B-Bladder’’ an Ileocolonic Neobladder with a Chimney: Surgical Technique and Long-Term Results Jack Baniela,b, Raanan Tala,b,* a
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Institute of Urology, Rabin Medical Center, Beilinson Campus, 49100 Petah Tikva, Israel
b
Accepted 19 January 2004 Available online 10 February 2004
Abstract Objectives: A modified version of the ‘‘Le Bag’’ ileocolonic neobladder with a ‘‘Studer’’-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described. Methods: Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years. Results: The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months. Conclusions: The B-bladder maintains the simplicity of preparation of the original ‘‘Le-Bag’’ neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent. # 2004 Elsevier B.V. All rights reserved. Keywords: Neobladder; Urinary diversion; Bladder reconstruction
1. Introduction Orthotopic neobladders are increasingly used as a method for urinary diversion after radical cystectomy for muscle-invasive bladder cancer. Many different types of orthotopic neobladders have been described in the literature since the 1980s. Nowadays they can be constructed without compromising cancer control, to allow for a better quality of life [1–5], and surgeons continue to seek still better techniques to minimize complications. Since Camey [6] offered his version of an ileal segment connected in its midst to the urethra and *
Corresponding author. Tel. þ972-3-6045196/9376563; Fax: þ972-3-6045196/9376569. E-mail address: [email protected] (R. Tal).
implantation of the ureters to each end, much advance has been made. While bowel detubularization has been accepted as a primary factor for the fashioning of a low pressure and effective volume bladder, the many techniques available to date vary in choice of bowel segment (ileum, ileo-colon, colon, sigmoid) and method of ureterointestinal anastomosis. Although each author presents data to his or her advantage, no single technique has proven to be of significant advantage over another. In the present paper, we introduce a chimney modification of the ileocolonic (‘‘Le Bag’’) neobladder [7], which maintains the simplicity of the original construction while gaining the advantages of ureteral anastomosis to a chimney. The surgical technique, perioperative complications and long-term results, including cancer control and continence, are described.
0302-2838/$ – see front matter # 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2004.01.013
J. Baniel, R. Tal / European Urology 45 (2004) 794–798
2. Methods The study included 29 patients (24 men, 5 women) with a preoperative diagnosis of invasive bladder cancer, treated in our center from 1995 to 2002. All underwent radical cystectomy and urinary diversion to an orthotopic neobladder made of terminal ileum and ascending colon with an ileal chimney, after giving their informed consent. Their charts were reviewed for preoperative (age, gender, disease status, creatinine level), perioperative (procedure duration, complications, morbidity) and postoperative data (imaging studies, blood tests results, continence, complications, morbidity). Patients, followed up for less than a year, were excluded. All operations were performed by a single surgeon (J.B.). Tumor stage was high-grade recurrent T1, T2 or T3. Preoperative imaging studies, including chest, abdominal and pelvic computerized tomography (CT), indicated node-negative disease with no evidence of distant metastases in all cases. Older age was not a contraindication for bladder reconstruction, but patients with significant co-morbid medical problems or poor functional status underwent urinary diversion to an ileal conduit rather than a neobladder. Postoperatively, patients were examined at 1 month, then every 3 months for the first year, and every 6 months thereafter. Follow-up imaging studies included abdominal ultrasound at 1, 3, 6 and 18 months and abdominal and pelvic CT and chest X-ray annually for the first 2 years. Thereafter, abdominal ultrasound was performed every 6 months and abdominal and pelvic CT and chest X-ray once yearly. Late complications were defined as those occurring more than one month postoperatively. Patients with complications (e.g., hydronephrosis, recurrent urinary tract infections, incontinence, deterioration of renal function) underwent additional imaging studies (excretory urography, voiding cystourethrography or renal scan), as needed. In addition, blood was tested for creatinine level every 3 months and for bicarbonate, vitamin B12, and folic acid levels every 6 months. Urodynamic studies were performed in the first 10 of the 29 patients to learn the qualities of the neobladder. Continence was evaluated by patient self-report during the follow-up visits. None of the 29 patients was lost to follow-up. Median duration of follow-up was 3.4 years (range: 1.1– 8.0 years).
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is detubularized throughout its entire length, including the ileocecal valve and up to the corresponding length of ileum. Care is taken to spare the lowermost part of the right colon. The proximal part of the ileum is left intact to serve as the antireflux mechanism (Fig. 1A). The posterior part of the neobladder is closed side-toside, colon-to-ileum, with continuous 3-0 Vicryl sutures. The anterior lower half of the neobladder is also sutured. The most dependent part of the cecum is
3. Surgical technique The first stage of the operation consists of bilateral pelvic lymphadenectomy of internal and external iliac lymph-nodes, up to the bifurcation of the common iliac vein followed by radical cystectomy with careful sparing of the urethra. The second (reconstructive) stage begins only after frozen-section pathology study confirms that the lymph nodes are free of tumor. The right colon is mobilized by incising along the peritoneum to beyond the right flexure of the colon, so that the cecum can be easily brought down to the urethral stump. Appendectomy is performed. Thirty to thirty-five centimeters of small bowel continuous with an adjacent 15–20 cm of right colon, including the cecum, are isolated from the alimentary tract, and an ileocolonic stapled end-to-side anastomosis is performed to re-establish bowel continuation. The colon
Fig. 1. Surgical technique. (A) A bowel segment including the terminal ileum, cecum and ascending colon is isolated from the alimentary tract. The bowel is detubularized (dashed line), except for the proximal 15–20 cm, which serve as a chimney. (B) The neobladder is formed by suturing the small bowel and large bowel side to side, with ureteral anastomosis to the chimney.
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inserted anteriorly through the colonic part of the reservoir, and the reservoir is closed. Closed 16 Fr silicone vacuum drains are left on each side of the neobladder in the pelvis. A cystogram of the B-bladder is depicted in Fig. 2.
4. Results
Fig. 2. A cystogram showing the reconstructed neobladder.
identified and anastomosed to the urethra over a 20 Fr catheter. Both ureters are shortened to just the length needed to reach the proximal part of the ileal segment without tension. They are spatulated and anastomosed end-to-side to the ileum over appropriate single J stents (Fig. 1B). The stents are passed through the colonic wall and exteriorized. A 22 Fr Malecot catheter is
The procedure was technically successful in 29 patients. In 2 patients the mesentery of the right colon was too short to allow mobilization of the right colon to the pelvis and a small bowel was used to create a ‘‘Studer type’’ neobladder. There were no intraoperative or perioperative (within 30 days) deaths. Operation time was acceptable (Table 1), with no difference between male and female patients, and decreased with experience. Two patients underwent nephroureterectomy as a part of the same operation. (One had a nonfunctioning right kidney and the other had a renal mass, which was later found to be an upper tract urothelial carcinoma.) Early complications consisted of one case of fascial dehiscence. Ten patients had late complications: recurrent urinary tract infection in 5 (17%), uretero-neobladder anastomotic stricture in 2 renal units (3%), and acute urinary retention which resolved on catheterization, hernia in scar, and acute renal failure without hydronephrosis on imaging studies in 1 patient each. The acute renal failure occurred in the patient who underwent nephroureterectomy for a non-functioning right kidney during the radical cystectomy. His creatinine level returned to normal after conservative management, and no invasive procedure was needed. None of the patients had chronic renal failure, as reflected by normal serum creatinine levels (mean S:D::
Table 1 The ‘‘B-bladder’’—operative results in 29 patients No. of patients (%) Age (years) a
Operative time (hours) For male patients For female patients
Continence Day Night Time to achieve continence (months) Urodynamic studies Neoblader volume (milliliter) Flow (milliliter per second) a
Mean S.D.
95%CI for the mean
Range
61.1 8.9
57.7–64.5
33.1–78.6
5.8 0.8 5.8 0.8 5.8 0.9
5.5–6.1 5.5–6.1 5.5–6.1
4.5–7.9 4.5–7.9 4.8–6.7
3.8 3.6
2.4–5.2
1.0–10.8
493 165 22.2 6.5
430–555 19.7–24.2
370–840 13.7–29.9
28/29 (96) 26/29 (89)
For bilateral lymphadenectomy, radical cystectomy and bladder reconstruction. Patients who also underwent nephroureterectomy (n ¼ 2) are excluded.
J. Baniel, R. Tal / European Urology 45 (2004) 794–798
1:1 0:14 mg%, range: 0.9–1.4 mg%). Vitamin B12 and folic acid levels were all within normal range as well. Bicarbonate levels measured from 14.9 to 29.8 mEq/l (mean S:D:: 23:8 5:0 mEq/l), and none of the patients needed replacement therapy. Continence results are shown in Table 1. Urodynamic evaluation was performed in the first 10 patients at 3–6 months. Relevant parameters of volume and flow are depicted in Table 1. In 5 patients (17%), we initiated self-catheterization before bedtime to improve night continence, though the average post-voiding residual during the day did not exceed 100 ml. One patient required diapers or penile clamp at night and required up to 2–3 pads per day. Two patients had frequent loose stools at the initial postoperative period with abdominal pains and cramping. These symptoms spontaneously subsided after 3–6 months. During the follow-up period, 11 patients (38%) died of disease progression with distant metastases. Only one patient had an early tumor recurrence in the pelvis and underwent sigmoidectomy, resection of the neobladder, and urinary diversion to an ileal conduit. Median survival was 71.1 months.
5. Discussion With recent developments in anesthesiology and surgical techniques, neobladder construction can now be performed with acceptable morbidity, providing improved quality of life, better body image, and improved sexual function, without compromising cancer control [8–10]. Many types and modifications of neobladder have been described, but there is no consensus on the best configuration. An ideal neobladder should be easy and safe to build, provide sufficient volume to store physiologic amounts of urine, and be easily emptied with minimal urine residuals. Patients should achieve full continence during both daytime and nighttime, and perioperative and long-term complications should be kept to a minimum. The Studer neobladder and modified ileocolonic neobladders are among the most commonly used neobladders for which long-term data are available [11–13]. Usually, surgeons adopt a certain technique they feel comfortable with and one or two alternatives. Since most urologists do only several reconstructions a year, it would be best to adopt the one that is easiest, quickest, and has best longterm results. Following this rule we encountered several technical obstacles during neobladders construction. The Studer technique was slightly complicated because of the need to fold the bowel twice to obtain a large volume reservoir, and it took long time to perform. The
797
same was true for the Hautmann-like reservoir, where long borders of bowel have to be sutured. Anastomosing an ileal reservoir to the urethra, in our hands, was found to be slightly cumbersome owing to the constant proximity of the suture line or the mesentery to the most dependent part of bowel chosen for the neobladder opening. This problem is overcome with the B-bladder using the ileocolonic segment, where the most dependent part is the cecum which is easy to manipulate and free of obstacles. The ileocolonic segment needs only to be adjoined side-to-side posteriorly and anteriorly, which is easier and faster. Incorporating the ileal chimney used by Studer for antireflux and performing a Bricker-type ureteroileal anastomosis reduced the relatively significant number of distal ureteral strictures and other ureteral complications encountered in performing Hautmann reservoirs. Having an additional segment available for ureteral anastomosis enables resection of the more distal part of the ureter which is prone to ischemia and is the cause of most late ureteric strictures [11]. The ability to manipulate the proximal antireflux segment to the left or right can compensate for lack of length of a ureter or in case of a patient with a single renal unit. The mobility of the chimney may also facilitate access to the uretero-neobladder anastomoses in case of anastomotis-related complications and a need for a revision or reanastomosis. The simplicity of the procedure is reflected here by the acceptable operation time and by the short learning curve for a surgeon who is familiar with the technique of radical cystectomy and diversion to other types of neobladders. The literature is inconsistent about gastrointestinal complications of bladder reconstruction. The use of the terminal ileum was not advocated because of the potential risk of vitamin B12, bile acid malabsorption, and resultant diarrhea. Exclusion of the ileocecal valve from the normal alimentary tract and interference with feces transit time may also account for diarrhea in these patients. Roth et al. [14] encountered a 2-fold risk of diarrhea in patients in whom an ileocecal segment was used compared to patients in whom a 50–60 cm ileal segment was used. In our study group there were no reports of chronic diarrhea and most patients have regular bowel movements after 2–3 months. Only 2 patients had gastrointestinal symptoms lasting up to 6 months and spontaneous remission was the rule. Moreover, as cystectomy is usually performed in older patients usually suffering from chronic constipation, increase in the frequency of bowel movements does not seem to be a major problem. Patients with neurogenic bladders, after radiotherapy or with known chronic diarrhea are at higher risk for gastrointestinal complications [15], and this must be taken
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J. Baniel, R. Tal / European Urology 45 (2004) 794–798
into account when choosing a certain segment for reconstruction. During the available follow-up period all patients maintained normal serum levels of vitamin B12 and folic acid. However, a longer follow-up period is needed to conclude that exclusion of the bowel segment used for the reconstruction, including a terminal ileum segment, from the alimentary tract does not lead to vitamin B12 or folic acid deficiencies. Overall, the complication rate was acceptable, and there were no perioperative deaths. Cancer control and long-term survival were also satisfactory. The reconstructive stage of the operation, i.e., formation of the neobladder, did not compromise the oncologic stage of the operation, i.e., pelvic lymphadenectomy and radical excision of the bladder. Finally, continence results among our patients were excellent, for both daytime and night, although 17% used catheterization intermittently, mainly before bedtime. These excellent
continence results may be accounted for by the relatively young age of subjects in our series (mean age: 61.1 years), however, they are in accordance to previous reports [16–18].
6. Conclusions We describe a new chimney modification of the ileocolonic neobladder that is as simple to perform as the original technique while adding the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications and the long-term results with regard to cancer control, continence and complications are excellent. The search for the ideal neobladder may offer patients a better quality of life and improved well-being without adversely affecting long-term survival.
References [1] Bjerre BD, Johansen C, Steven K. Health-related quality of life after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire survey. Br J Urol 1995;75:200– 5. [2] Dutta SC, Chang SC, Coffey CS, Smith Jr JA, Jack G, Cookson MS. Health related quality of life assessment after radical cystectomy: comparison of ileal conduit with continent orthotopic neobladder. J Urol 2002;168:164–7. [3] Hara I, Miyake H, Hara S, Gotoh A, Nakamura I, Okada H, et al. Health-related quality of life after radical cystectomy for bladder cancer: a comparison of ileal conduit and orthotopic bladder replacement. BJU Int 2002;89:10–3. [4] Hobisch A, Tosun K, Kinzl J, Kemmler G, Bartsch G, Holtl L, et al. Life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. Semin Urol Oncol 2001;19:18–23. [5] Henningsohn L, Steven K, Kallestrup EB, Steineck G. Distressful symptoms and well-being after radical cystectomy and orthotopic bladder substitution compared with a matched control population. J Urol 2002;168:168–74. [6] Camey M. Bladder replacement by ileocystoplasty following radical cystectomy. Semin Urol 1987;5:8–14. [7] Light JK, Scardino PT. Radical cystectomy with preservation of sexual and urinary function. Use of the ileocolonic pouch (‘‘Le Bag’’). Urol Clin North Am 1986;13:261–9. [8] Parekh DJ, Gilbert WB, Koch MO, Smith Jr JA. Continent urinary reconstruction versus ileal conduit: a contemporary single-institution comparison of perioperative morbidity and mortality. Urology 2000; 55:852–5. [9] Parekh DJ, Clark T, O’Connor J, Jung C, Chang SS, Cookson M, et al. Orthotopic neobladder following radical cystectomy in patients
[10]
[11]
[12]
[13]
[14]
[15] [16]
[17]
[18]
with high perioperative risk and co-morbid medical conditions. J Urol 2002;168:2454–6. Yossepowitch O, Dalbagni G, Golijanin D, Donat SM, Bochner BH, Herr HW, et al. Orthotopic urinary diversion after cystectomy for bladder cancer: implications for cancer control and patterns of disease recurrence. J Urol 2003;169:177–81. Studer UE, Danuser H, Hochreiter W, Springer JP, Turner WH, Zingg EJ. Summary of 10 years’ experience with an ileal lowpressure bladder substitute combined with an afferent tubular isoperistaltic segment. World J Urol 1996;14:29–39. Thuroff JW, Alken P, Riedmiller H, Jacobi GH, Hohenfellner R. 100 cases of Mainz pouch: continuing experience and evolution. J Urol 1988;140:283–8. Marshall FF, Mostwin JL, Radebaugh LC, Walsh PC, Brendler CB. Ileocolic neobladder post-cystectomy: continence and potency. J Urol 1991;145:502–4. Roth S, Semjonow A, Waldner M, Hertle L. Risk of bowel dysfunction with diarrhea after continent urinary diversion with ileal and ileocecal segments. J Urol 1995;154:1696–9. N’Dow J, Leung HY, Marshall C, Neal DE. Bowel dysfunction after bladder reconstruction. J Urol 1998;159:1470–4. Soulie M, Seguin P, Mouly P, Thoulouzan M, Pontonnier F, Plante P. Assessment of morbidity and functional results in bladder replacement with Hautmann ileal neobladder after radical cystectomy: a clinical experience in 55 highly selected patients. Urology 2001;58:707–11. Deliveliotis C, Alargoff E, Skolarikos A, Varkarakis I, Argyropoulos V, Dimopoulos C. Modified ileal neobladder for continent urinary diversion: experience and results. Urology 2001;58:712–6. Hautmann RE. Urinary diversion: ileal conduit to neobladder. J Urol 2003;169:834–42.
European Urology 45 (2004) 794–798
The ‘‘B-Bladder’’ an Ileocolonic Neobladder with a Chimney: Surgical Technique and Long-Term Results Jack Baniela,b, Raanan Tala,b,* a
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Institute of Urology, Rabin Medical Center, Beilinson Campus, 49100 Petah Tikva, Israel
b
Accepted 19 January 2004 Available online 10 February 2004
Abstract Objectives: A modified version of the ‘‘Le Bag’’ ileocolonic neobladder with a ‘‘Studer’’-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described. Methods: Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years. Results: The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months. Conclusions: The B-bladder maintains the simplicity of preparation of the original ‘‘Le-Bag’’ neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent. # 2004 Elsevier B.V. All rights reserved. Keywords: Neobladder; Urinary diversion; Bladder reconstruction
1. Introduction Orthotopic neobladders are increasingly used as a method for urinary diversion after radical cystectomy for muscle-invasive bladder cancer. Many different types of orthotopic neobladders have been described in the literature since the 1980s. Nowadays they can be constructed without compromising cancer control, to allow for a better quality of life [1–5], and surgeons continue to seek still better techniques to minimize complications. Since Camey [6] offered his version of an ileal segment connected in its midst to the urethra and *
Corresponding author. Tel. þ972-3-6045196/9376563; Fax: þ972-3-6045196/9376569. E-mail address: [email protected] (R. Tal).
implantation of the ureters to each end, much advance has been made. While bowel detubularization has been accepted as a primary factor for the fashioning of a low pressure and effective volume bladder, the many techniques available to date vary in choice of bowel segment (ileum, ileo-colon, colon, sigmoid) and method of ureterointestinal anastomosis. Although each author presents data to his or her advantage, no single technique has proven to be of significant advantage over another. In the present paper, we introduce a chimney modification of the ileocolonic (‘‘Le Bag’’) neobladder [7], which maintains the simplicity of the original construction while gaining the advantages of ureteral anastomosis to a chimney. The surgical technique, perioperative complications and long-term results, including cancer control and continence, are described.
0302-2838/$ – see front matter # 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2004.01.013
J. Baniel, R. Tal / European Urology 45 (2004) 794–798
2. Methods The study included 29 patients (24 men, 5 women) with a preoperative diagnosis of invasive bladder cancer, treated in our center from 1995 to 2002. All underwent radical cystectomy and urinary diversion to an orthotopic neobladder made of terminal ileum and ascending colon with an ileal chimney, after giving their informed consent. Their charts were reviewed for preoperative (age, gender, disease status, creatinine level), perioperative (procedure duration, complications, morbidity) and postoperative data (imaging studies, blood tests results, continence, complications, morbidity). Patients, followed up for less than a year, were excluded. All operations were performed by a single surgeon (J.B.). Tumor stage was high-grade recurrent T1, T2 or T3. Preoperative imaging studies, including chest, abdominal and pelvic computerized tomography (CT), indicated node-negative disease with no evidence of distant metastases in all cases. Older age was not a contraindication for bladder reconstruction, but patients with significant co-morbid medical problems or poor functional status underwent urinary diversion to an ileal conduit rather than a neobladder. Postoperatively, patients were examined at 1 month, then every 3 months for the first year, and every 6 months thereafter. Follow-up imaging studies included abdominal ultrasound at 1, 3, 6 and 18 months and abdominal and pelvic CT and chest X-ray annually for the first 2 years. Thereafter, abdominal ultrasound was performed every 6 months and abdominal and pelvic CT and chest X-ray once yearly. Late complications were defined as those occurring more than one month postoperatively. Patients with complications (e.g., hydronephrosis, recurrent urinary tract infections, incontinence, deterioration of renal function) underwent additional imaging studies (excretory urography, voiding cystourethrography or renal scan), as needed. In addition, blood was tested for creatinine level every 3 months and for bicarbonate, vitamin B12, and folic acid levels every 6 months. Urodynamic studies were performed in the first 10 of the 29 patients to learn the qualities of the neobladder. Continence was evaluated by patient self-report during the follow-up visits. None of the 29 patients was lost to follow-up. Median duration of follow-up was 3.4 years (range: 1.1– 8.0 years).
795
is detubularized throughout its entire length, including the ileocecal valve and up to the corresponding length of ileum. Care is taken to spare the lowermost part of the right colon. The proximal part of the ileum is left intact to serve as the antireflux mechanism (Fig. 1A). The posterior part of the neobladder is closed side-toside, colon-to-ileum, with continuous 3-0 Vicryl sutures. The anterior lower half of the neobladder is also sutured. The most dependent part of the cecum is
3. Surgical technique The first stage of the operation consists of bilateral pelvic lymphadenectomy of internal and external iliac lymph-nodes, up to the bifurcation of the common iliac vein followed by radical cystectomy with careful sparing of the urethra. The second (reconstructive) stage begins only after frozen-section pathology study confirms that the lymph nodes are free of tumor. The right colon is mobilized by incising along the peritoneum to beyond the right flexure of the colon, so that the cecum can be easily brought down to the urethral stump. Appendectomy is performed. Thirty to thirty-five centimeters of small bowel continuous with an adjacent 15–20 cm of right colon, including the cecum, are isolated from the alimentary tract, and an ileocolonic stapled end-to-side anastomosis is performed to re-establish bowel continuation. The colon
Fig. 1. Surgical technique. (A) A bowel segment including the terminal ileum, cecum and ascending colon is isolated from the alimentary tract. The bowel is detubularized (dashed line), except for the proximal 15–20 cm, which serve as a chimney. (B) The neobladder is formed by suturing the small bowel and large bowel side to side, with ureteral anastomosis to the chimney.
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J. Baniel, R. Tal / European Urology 45 (2004) 794–798
inserted anteriorly through the colonic part of the reservoir, and the reservoir is closed. Closed 16 Fr silicone vacuum drains are left on each side of the neobladder in the pelvis. A cystogram of the B-bladder is depicted in Fig. 2.
4. Results
Fig. 2. A cystogram showing the reconstructed neobladder.
identified and anastomosed to the urethra over a 20 Fr catheter. Both ureters are shortened to just the length needed to reach the proximal part of the ileal segment without tension. They are spatulated and anastomosed end-to-side to the ileum over appropriate single J stents (Fig. 1B). The stents are passed through the colonic wall and exteriorized. A 22 Fr Malecot catheter is
The procedure was technically successful in 29 patients. In 2 patients the mesentery of the right colon was too short to allow mobilization of the right colon to the pelvis and a small bowel was used to create a ‘‘Studer type’’ neobladder. There were no intraoperative or perioperative (within 30 days) deaths. Operation time was acceptable (Table 1), with no difference between male and female patients, and decreased with experience. Two patients underwent nephroureterectomy as a part of the same operation. (One had a nonfunctioning right kidney and the other had a renal mass, which was later found to be an upper tract urothelial carcinoma.) Early complications consisted of one case of fascial dehiscence. Ten patients had late complications: recurrent urinary tract infection in 5 (17%), uretero-neobladder anastomotic stricture in 2 renal units (3%), and acute urinary retention which resolved on catheterization, hernia in scar, and acute renal failure without hydronephrosis on imaging studies in 1 patient each. The acute renal failure occurred in the patient who underwent nephroureterectomy for a non-functioning right kidney during the radical cystectomy. His creatinine level returned to normal after conservative management, and no invasive procedure was needed. None of the patients had chronic renal failure, as reflected by normal serum creatinine levels (mean S:D::
Table 1 The ‘‘B-bladder’’—operative results in 29 patients No. of patients (%) Age (years) a
Operative time (hours) For male patients For female patients
Continence Day Night Time to achieve continence (months) Urodynamic studies Neoblader volume (milliliter) Flow (milliliter per second) a
Mean S.D.
95%CI for the mean
Range
61.1 8.9
57.7–64.5
33.1–78.6
5.8 0.8 5.8 0.8 5.8 0.9
5.5–6.1 5.5–6.1 5.5–6.1
4.5–7.9 4.5–7.9 4.8–6.7
3.8 3.6
2.4–5.2
1.0–10.8
493 165 22.2 6.5
430–555 19.7–24.2
370–840 13.7–29.9
28/29 (96) 26/29 (89)
For bilateral lymphadenectomy, radical cystectomy and bladder reconstruction. Patients who also underwent nephroureterectomy (n ¼ 2) are excluded.
J. Baniel, R. Tal / European Urology 45 (2004) 794–798
1:1 0:14 mg%, range: 0.9–1.4 mg%). Vitamin B12 and folic acid levels were all within normal range as well. Bicarbonate levels measured from 14.9 to 29.8 mEq/l (mean S:D:: 23:8 5:0 mEq/l), and none of the patients needed replacement therapy. Continence results are shown in Table 1. Urodynamic evaluation was performed in the first 10 patients at 3–6 months. Relevant parameters of volume and flow are depicted in Table 1. In 5 patients (17%), we initiated self-catheterization before bedtime to improve night continence, though the average post-voiding residual during the day did not exceed 100 ml. One patient required diapers or penile clamp at night and required up to 2–3 pads per day. Two patients had frequent loose stools at the initial postoperative period with abdominal pains and cramping. These symptoms spontaneously subsided after 3–6 months. During the follow-up period, 11 patients (38%) died of disease progression with distant metastases. Only one patient had an early tumor recurrence in the pelvis and underwent sigmoidectomy, resection of the neobladder, and urinary diversion to an ileal conduit. Median survival was 71.1 months.
5. Discussion With recent developments in anesthesiology and surgical techniques, neobladder construction can now be performed with acceptable morbidity, providing improved quality of life, better body image, and improved sexual function, without compromising cancer control [8–10]. Many types and modifications of neobladder have been described, but there is no consensus on the best configuration. An ideal neobladder should be easy and safe to build, provide sufficient volume to store physiologic amounts of urine, and be easily emptied with minimal urine residuals. Patients should achieve full continence during both daytime and nighttime, and perioperative and long-term complications should be kept to a minimum. The Studer neobladder and modified ileocolonic neobladders are among the most commonly used neobladders for which long-term data are available [11–13]. Usually, surgeons adopt a certain technique they feel comfortable with and one or two alternatives. Since most urologists do only several reconstructions a year, it would be best to adopt the one that is easiest, quickest, and has best longterm results. Following this rule we encountered several technical obstacles during neobladders construction. The Studer technique was slightly complicated because of the need to fold the bowel twice to obtain a large volume reservoir, and it took long time to perform. The
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same was true for the Hautmann-like reservoir, where long borders of bowel have to be sutured. Anastomosing an ileal reservoir to the urethra, in our hands, was found to be slightly cumbersome owing to the constant proximity of the suture line or the mesentery to the most dependent part of bowel chosen for the neobladder opening. This problem is overcome with the B-bladder using the ileocolonic segment, where the most dependent part is the cecum which is easy to manipulate and free of obstacles. The ileocolonic segment needs only to be adjoined side-to-side posteriorly and anteriorly, which is easier and faster. Incorporating the ileal chimney used by Studer for antireflux and performing a Bricker-type ureteroileal anastomosis reduced the relatively significant number of distal ureteral strictures and other ureteral complications encountered in performing Hautmann reservoirs. Having an additional segment available for ureteral anastomosis enables resection of the more distal part of the ureter which is prone to ischemia and is the cause of most late ureteric strictures [11]. The ability to manipulate the proximal antireflux segment to the left or right can compensate for lack of length of a ureter or in case of a patient with a single renal unit. The mobility of the chimney may also facilitate access to the uretero-neobladder anastomoses in case of anastomotis-related complications and a need for a revision or reanastomosis. The simplicity of the procedure is reflected here by the acceptable operation time and by the short learning curve for a surgeon who is familiar with the technique of radical cystectomy and diversion to other types of neobladders. The literature is inconsistent about gastrointestinal complications of bladder reconstruction. The use of the terminal ileum was not advocated because of the potential risk of vitamin B12, bile acid malabsorption, and resultant diarrhea. Exclusion of the ileocecal valve from the normal alimentary tract and interference with feces transit time may also account for diarrhea in these patients. Roth et al. [14] encountered a 2-fold risk of diarrhea in patients in whom an ileocecal segment was used compared to patients in whom a 50–60 cm ileal segment was used. In our study group there were no reports of chronic diarrhea and most patients have regular bowel movements after 2–3 months. Only 2 patients had gastrointestinal symptoms lasting up to 6 months and spontaneous remission was the rule. Moreover, as cystectomy is usually performed in older patients usually suffering from chronic constipation, increase in the frequency of bowel movements does not seem to be a major problem. Patients with neurogenic bladders, after radiotherapy or with known chronic diarrhea are at higher risk for gastrointestinal complications [15], and this must be taken
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into account when choosing a certain segment for reconstruction. During the available follow-up period all patients maintained normal serum levels of vitamin B12 and folic acid. However, a longer follow-up period is needed to conclude that exclusion of the bowel segment used for the reconstruction, including a terminal ileum segment, from the alimentary tract does not lead to vitamin B12 or folic acid deficiencies. Overall, the complication rate was acceptable, and there were no perioperative deaths. Cancer control and long-term survival were also satisfactory. The reconstructive stage of the operation, i.e., formation of the neobladder, did not compromise the oncologic stage of the operation, i.e., pelvic lymphadenectomy and radical excision of the bladder. Finally, continence results among our patients were excellent, for both daytime and night, although 17% used catheterization intermittently, mainly before bedtime. These excellent
continence results may be accounted for by the relatively young age of subjects in our series (mean age: 61.1 years), however, they are in accordance to previous reports [16–18].
6. Conclusions We describe a new chimney modification of the ileocolonic neobladder that is as simple to perform as the original technique while adding the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications and the long-term results with regard to cancer control, continence and complications are excellent. The search for the ideal neobladder may offer patients a better quality of life and improved well-being without adversely affecting long-term survival.
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