FEMALE UROLOGY

Experience with the orthotopic ileal neobladder in women: a mid-term follow-up
Nesrallah LJ, Almeida FG, Dall’oglio MF, Nesrallah AJ, Srougi M
Federal University of Sao Paulo (UNIFESP-EPM), Sao Paulo, Brazil
BJU Int. 2005; 95: 1045-7

• Objective: 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.
• Results: 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.
• Conclusion: 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.
  
  
• Editorial Comment
  The authors reviewed their experience with orthotopic ileal neobladder in a population of 29 women. The mean long term follow-up was 27.5 months. The authors point out their results as well as their specific technique and commentary on same. They noted that the bladder capacity stabilized at an appropriate volume at six months with 14% of patients having nocturnal incontinence, 10% of patients requiring self intermittent catheterization to empty their reservoir and 2.5% of the study group having stress urinary incontinence.
  This is an excellent review and instructional presentation by these authors. The paper is extremely strong in the area of voiding dysfunction. The use of a voiding diary and the strict criteria of urinary incontinence should be applauded. The authors’ notations on their surgical technique and its positive effects should be carefully read by others performing this type of surgery and reconstruction. The very surgically precise technique including nerve sparing has done nothing but reward these physicians with excellent postoperative results. In addition, their explanation of the use of 40 cm of ileal segment for reconstruction and its positive results should be noted. A reader may question why this group required their patients with a residual > 100 cc to undergo clean intermittent catheterization. Perhaps these patients had recurring urinary tract infection or voiding dysfunction that was not clearly stated. In view of this excellent study group and their notations on the quality of life of patients after cystectomy, the authors if able should consider performing a sexual function questionnaire such as the PISQ and report their results on the sexual habits of this group that have had undergone a major yet successful urinary reconstruction. This may have a great value. The study group had a very low level of postoperative stress urinary incontinence. The authors’ opinion on options for this subgroup would be of keen interest in view of other reports describing postoperative catastrophes at the time of sub urethral sling placement (1). Would they consider a trans obturator technique in view of its extra peritoneal position? The ileal conduit has been used for an extended period of time, even much to the surprise of the original describers (2). With excellent publications such as this, ileal neo-bladders will continue to increase in use when appropriate thus potentially one day surpassing ileal conduits as the most frequent urinary diversion in women. If dismissive of the orthotopic ileal neobladder, one should not discount the complications associated without diversion including stomal problems, peristomal dermatitis, stomal ischemia, peristomal hernias as well as stomal prolapse (2).

References
1. Quek ML, Ginsberg DA, Wilson S, Skinner EC, Stein JP, Skinner DG: Pubovaginal slings for stress urinary incontinence following radical cystectomy and orthotopic neobladder reconstruction in women. J Urol. 2004; 172: 219-21.
2. Hinman Jr F: Atlas of Urologic Surgery. Philadelphia, WB Saunders Co, 1989.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida, USA