The S Shaped Orthotopic Ileal Neobladder Substitute Incorporating A New Seromuscular Antireflux Technique (Split Ileal End) In A Series Of 50

Main Category: Urology / Nephrology
Also Included In: Cancer / Oncology
Article Date: 28 Oct 2007 - 0:00 PDT

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UroToday.com - Bladder cancer is considered the most prevalent malignant tumor among males in Egypt. Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer and may be considered the gold standard with which other forms of diversion are compared. Incorporation of antireflux system in orthotopic ileal neobladder substitutes is important in protecting the upper urinary tract in all patients undergoing continent diversion with a reasonable life expectancy. If this were not important, why is it that normal human bladder anatomy has evolved with an effective antireflux mechanism? Indeed, many antireflux techniques have been developed but the multiplicity of these techniques suggests that an ideal solution has not been found. All antireflux anastmosis have an inherent risk of functional failure (Hautmann, 2003).

Patients with carcinoma in situ of the prostatic urethra, tumors near bladder neck or infiltrating the prostate, multifocal papillary tumors, history of upper tract tumors or positive margins on frozen section of the transected proximal urethra must be excluded. For these patients, continent cutaneous diversion using the same technique will be evolved soon. After radical cystectomy in females, both ureters are intussuscepted in modified Sigma pouch but most of the females now prefer orthotopic ileal neobladder (Denewer, 1998).

The new technique, which prevents reflux, has several advantages compared with antireflux techniques: technical simplicity and the procedure is suitable for all types of ureters including normal, dilated, short and irradiated ureters. It allows a non obstructed unidirectional flow of urine with minimal rate of stenosis and/or surgical revision so; it can protect the upper urinary tract. The use of foreign material like staples or meshes is avoided and the antireflux system is constructed from a minimal length of bowel segment decreasing metabolic complications associated with malabsorption or resorption. The afferent short limb provides extra length to reach the ureter, a tension free anastomosis, no risks of ureteral angulation with neobladder filling, and the possibility to resect the ureter far above the bladder, thus avoiding ureteral ischemia and distal recurrence. With intermediate follow up the S pouch ileal neobladder incorporating the new antireflux technique appears to be effective in preventing reflux of urine without significantly increasing the incidence of obstruction. The clinical and functional results of S pouch ileal neobladder appear to be accepted. Despite these encouraging results prolonged follow up will be required to determine the durability and long term complications associated with orthotopic ileal neobladder.

References:

-- Hautmann, R.E. (2003): Urinary diversion: ileal conduit to neobladder. J.Urol., 169:834.

-- Denewer, A (1998): A low-pressure rectosigmoid pouch created by side-to-side anastomosis with a stapling technique and sigmoid colon intussusception as an antireflux procedure. British Journal of urology 81:856-861.

Written by Adel T. Mohamed Denewer, MD, as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

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