| RE:
GYNECOLOGIC-TRACT SPARING EXTRA PERITONEAL RETROGRADE RADICAL CYSTECTOMY
WITH NEOBLADDER
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JAGDEESH N. KULKARNI,
S. JAMAL RIZVI, U. PURUSHOTTHAMA ACHARYA, K. S. SHIVA KUMAR, P. TIWARI
Department
of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, India
Int
Braz J Urol, 34: 180-190, 2008
To the Editor:
Bladder
cancer is considered the most prevalent malignant tumor affecting male
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 (1).
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 (2).
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
1. Hautmann
RE: Urinary diversion: ileal conduit to neobladder. J Urol. 2003; 169:
834-42.
2. Denewer A: A low-pressure rectosigmoid pouch created by side-to-side
anastomosis with a stapling technique and sigmoid colon intussusception
as an antireflux procedure. Br J Urol. 1998; 81: 856-61.
Dr.
Adel Denewer
Department of Surgical Oncology
Oncology Center, Mansoura University
Mansoura, Egypt
E-mail: adeldenewer@mans.edu.eg
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