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ORTHOTOPIC NEOBLADDER
Dr Prateek Laddha
SR Urology
CMC Ludhiana
HISTORY OF ORTHOTOPIC URINARY DIVERSION
• Since the early 1900s
• Ureterosigmoidostomy is the oldest form of urinary diver...
• Ureterosigmoidostomy remained the diversion of choice until the
late 1950s,
• but long-term electrolyte imbalance,
• upp...
• The ileal conduit is a technically simple, reliable form of urinary
diversion that became widely accepted and became the...
PATIENT SELECTION
• all patients who undergo radical cystectomy may be considered at
least potential candidates for orthot...
Oncologic Factors
Risk of Urethral Recurrence in Men
• Primary oncologic contraindication for orthotopic diversion is the
...
Risk of Urethral Recurrence in Women:
• Risk factors for urethral involvement included
• increased grade,
• stage, and
• l...
• However, approximately half of patients with bladder neck tumors
had a normal (tumor-free) proximal urethra.
• In all ca...
Locally Advanced Tumor Stage
• Many urologists are hesitant to perform continent orthotopic
diversion in patients with loc...
• most patients could anticipate normal neobladder function even in
the presence of locally recurrent disease.
• The low risk of local recurrence showed that in this cohort of patients
the oncologic efficacy of the operation was not ...
Patient-Related Factors
• Age
• The clear consensus is that chronologic age alone is not a contraindication
for continent ...
Body Habitus
• Obesity is not a contraindication
• Placing the urethral sutures and working with the thick bowel
mesentery...
• Manual Dexterity and Willingness to Do Self-Catheterization
• Urethral Stricture Disease or External Sphincter Damage
• ...
Prior Prostate Surgery or Bowel Resection
• Prior abdominal or pelvic surgery may also present challenges for the
surgeon ...
SURGICAL TECHNIQUES FOR CONTINENCE
PRESERVATION DURING RADICAL CYSTECTOMY
• Anterior Apical Dissection in the Male Patient...
• Care should be taken to avoid deep suture bites into the complex or
levator muscles, which could injure the continence m...
Preservation of the Urethra in the Female Patient
• A standard female cystectomy includes removal of the uterus, cervix,
a...
• A patient with a significant tumor at the bladder neck or with
palpable extension into the vaginal wall is a poor candid...
• Preparation of the female
urethra for an orthotopic
neobladder. The fatty tissue
overlying the anterior urethra is
swept...
• Regardless of the form of vaginal
reconstruction, a well-vascularized
omental pedicle graft should be
placed between the...
TECHNIQUES FOR ORTHOTOPIC
BLADDER SUBSTITUTION
• Choice of Bowel Segment
• excellent functional and clinical outcomes with...
• The primary disadvantage of using distal ileum lies in the potential
loss of absorption of vitamin B12.
• Isolation of t...
General Perioperative Management
• Ileal Reservoirs
• ileal reservoirs use from 60 to 75 cm of terminal ileum, which is
de...
Camey II
• The Camey II orthotopic substitute is a modification of the original
Camey bladder substitute, which was a simp...
Ileal Neobladder (Hautmann Pouch)
• This neobladder is an intentionally large-capacity, spheric (W
configuration) ileal re...
Construction of the Studer neobladder
(modified).
• Designated segments of terminal
ileum for construction of the
orthotop...
• The Studer pouch is constructed
from an isolated 44-cm ileal
segment (placed in an inverted U
configuration), which form...
• The previously incised ileal
mucosa is then oversewn with
two layers of a running 3-0
polyglycolic acid suture starting
...
• Construction of the antireflux
mechanism in the T pouch. The ileum is
divided between the proximal afferent
ileal segmen...
• The previously anchored distal
3- to 4-cm afferent ileal
segment is tapered over a 30-Fr
catheter on the antimesenteric
...
• A mucosa-to mucosa
anastomosis is performed
between the ostium of the
afferent segment and the edges
of the ileal flaps ...
• Once the reservoir is folded in
half, the anterior wall is closed
with a two-layer 3-0 polyglycolic
acid suture that is ...
• Each ureter is spatulated and a
standard bilateral end-to-side
ureteroileal anastomosis is
performed using interrupted 4...
• The reservoir is anastomosed to
the urethra using the previously
placed urethral sutures.
Colon and Ileocolic Pouches
Orthotopic Mainz Pouch (Mainz III)
Le Bag Pouch
• late complications with the ileal conduit such as
• peristomal hernia
• stomal stenosis
• pyelonephritis
• kidney stones...
• These clinical sequelae
• the high-pressure reflux of infected urine or
• obstruction of the upper urinary tract.
• It w...
• One of the earliest continent cutaneous diversions in humans was described by
Gilchrist and colleagues in 1950.
• This f...
• After Kock described his results in his initial 12 patients, Skinner
began performing this diversion in adults undergoin...
Problems
• stones,
• difficulty in catheterizing,
• peristomal hernias, and
• the development of leakage are potential pro...
Early and Late Complications
Both early and late complications may also be influenced by other
factors such as
- prior rad...
• Late complications not
• directly related to the diversion include bowel obstruction, ventral
• hernia, thrombotic event...
• Ventral hernias are quite common and may be in part related to the
need for increased abdominal pressure to empty the ne...
• primary late complications of orthotopic diversion that are directly
related to the diversion itself include
• incontine...
• Pouch perforation is rare in continent diversion in general, especially
in orthotopic diversion because outlet resistanc...
• CT scans will often be misinterpreted by radiologists or urologists
unfamiliar with the anatomy and/or the specific type...
• Pouch-vaginal fistula is a unique complication of orthotopic
neobladder in women that can be quite difficult to repair.
...
Incontinence:
• The evaluation and management of urinary incontinence after
orthotopic diversion should be delayed until t...
Follow up: NO CONSENSUS
• Early evaluation (first 4 months) to identify early ureteroileal anastomotic
strictures caused b...
QUALITY OF LIFE AFTER
URINARY DIVERSION
• Most quality-of-life studies that have evaluated and compared
patients undergoin...
•Thank You
Orthotopic neobladder
Orthotopic neobladder
Orthotopic neobladder
Orthotopic neobladder
Orthotopic neobladder
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Orthotopic neobladder

  1. 1. ORTHOTOPIC NEOBLADDER Dr Prateek Laddha SR Urology CMC Ludhiana
  2. 2. HISTORY OF ORTHOTOPIC URINARY DIVERSION • Since the early 1900s • Ureterosigmoidostomy is the oldest form of urinary diversion. • 1st reported urinary diversion into a segment of bowel  Simon in 1852. • A number of technical modifications of the ureterosigmoidostomy ensued, particularly related to the ureteral implantation technique (Hinman and Weyrauch, 1936). • (Leadbetter, 1951; Goodwin et al, 1953). introduction of an antireflux tunneled anastomosis of the ureter into the sigmoid colon • rates of obstruction and • ascending pyelonephritis in patients with ureterosigmoidostomy
  3. 3. • Ureterosigmoidostomy remained the diversion of choice until the late 1950s, • but long-term electrolyte imbalance, • upper tract obstruction and infection, and • secondary malignant neoplasms arising at the ureteral implantation site were observed • In 1950 Bricker refined and popularized  ileal conduit form of urinary diversion, • building on an original description by Zaayer in 1911 (Zaayer, 1911; Bricker, 1950).
  4. 4. • The ileal conduit is a technically simple, reliable form of urinary diversion that became widely accepted and became the gold standard to which other types of urinary diversion were compared until the 1980s. • It continues to be by far the most common form of urinary diversion performed throughout the world today for patients undergoing cystectomy. • Long-term complications with the [1970s]. • hyperchloremic metabolic acidosis and • pyelonephritis were substantially less common than in patients with ureterosigmoidostomy,
  5. 5. PATIENT SELECTION • all patients who undergo radical cystectomy may be considered at least potential candidates for orthotopic urinary diversion. • Factors can be divided into cancer-related factors and patient factors.
  6. 6. Oncologic Factors Risk of Urethral Recurrence in Men • Primary oncologic contraindication for orthotopic diversion is the presence of urothelial carcinoma at the urethral margin on intraoperative frozen section at the time of cystectomy. • It has been a practice to counsel patients with documented • prostatic mucosal, • ductal, or • stromal invasion about the increased risk of urethral recurrence if the urethra is left in situ, • weigh that risk against any perceived advantage of an orthotopic diversion.
  7. 7. Risk of Urethral Recurrence in Women: • Risk factors for urethral involvement included • increased grade, • stage, and • lymph node involvement, but the presence of CIS did not predict urethral involvement. • Vaginal wall involvement was also a major risk factor for urethral involvement. • The urethra can be safely preserved in selected female cystectomy patients provided that neither preoperative biopsy specimens of the bladder neck nor intraoperative frozen section specimens of the proximal urethra demonstrate any tumor or atypia.
  8. 8. • However, approximately half of patients with bladder neck tumors had a normal (tumor-free) proximal urethra. • In all cases, intraoperative frozen-section analysis of the proximal urethra correlated with and was correctly confirmed by final permanent section. • These results suggest that one may depend on the intraoperative frozen section to determine the feasibility of orthotopic diversion.
  9. 9. Locally Advanced Tumor Stage • Many urologists are hesitant to perform continent orthotopic diversion in patients with locally extensive disease. This is based on two factors: (1) concern about the possible impact of local recurrence on the neobladder itself and (2) a belief that these patients are doomed to suffer distant recurrence and have a shortened life expectancy and will not benefit from the neobladder. • If local tumor recurrence does develop in patients with an orthotopic diversion, only a minority will develop problems related to the urinary diversion itself.
  10. 10. • most patients could anticipate normal neobladder function even in the presence of locally recurrent disease.
  11. 11. • The low risk of local recurrence showed that in this cohort of patients the oncologic efficacy of the operation was not compromised include the • patient’s general health and social circumstances, • baseline renal function, • presence of a healthy urethra and functioning sphincter muscle, • manual dexterity, and • previous treatments including pelvic radiation, • prostate surgery, or • bowel resection.
  12. 12. Patient-Related Factors • Age • The clear consensus is that chronologic age alone is not a contraindication for continent diversion and that options should be considered for each patient on the basis of other factors • Renal Function • One of the most important contraindications for continent neobladder reconstruction is compromised renal function. • In patients with compromised renal function, hyperchloremic metabolic acidosis can develop along with worsening dehydration, uremia, nausea, and bone loss. • Serum creatinine level of < 1.7 to 2.2 mg/ dL (150 to 200 μmol/L) or an estimated CC of greater than 35 to 40 mL/min is recommended for patients considering continent diversion
  13. 13. Body Habitus • Obesity is not a contraindication • Placing the urethral sutures and working with the thick bowel mesentery may be challenging. • An obese patient may be better served with orthotopic diversion because of the difficulty constructing a functional conduit stoma with a very thick abdominal wall.
  14. 14. • Manual Dexterity and Willingness to Do Self-Catheterization • Urethral Stricture Disease or External Sphincter Damage • Severe urethral stricture disease in men and women is a contraindication for orthotopic diversion. • Prior Pelvic Radiation • Patients with prior radiation are at increased risk of several complications, even with an ileal conduit diversion. • Orthotopic lower urinary tract reconstruction can be performed after definitive, full-dose pelvic irradiation. • careful intraoperative tissue assessment and determination of the condition of the urethra, ureters, and bowel must be performed to make a final decision about the feasibility of orthotopic diversion
  15. 15. Prior Prostate Surgery or Bowel Resection • Prior abdominal or pelvic surgery may also present challenges for the surgeon performing orthotopic diversion. Patients who have had a prior radical prostatectomy may have a particularly difficult dissection around the proximal urethra at the prior vesicourethral anastomosis. • Short bowel syndrome
  16. 16. SURGICAL TECHNIQUES FOR CONTINENCE PRESERVATION DURING RADICAL CYSTECTOMY • Anterior Apical Dissection in the Male Patient • Attention to anatomic and surgical detail is important to optimize functional and clinical outcomes in patients undergoing orthotopic diversion. Minimal manipulation of the muscle fibers of the rhabdosphincter, fascial attachments, and corresponding innervation is essential to providing optimal urinary continence • If a nerve-sparing approach is planned, the urethra may be divided after the lateral pedicles are taken down to the bladder (anterior branches of the internal iliac vessels) before the posterior dissection is performed. The prostate is then dissected in a retrograde fashion off the rectum and bilateral neurovascular bundles, and the posterior pedicles are divided last.
  17. 17. • Care should be taken to avoid deep suture bites into the complex or levator muscles, which could injure the continence mechanism. • Frozen-section analysis of the circumferential distal urethral mucosal margin (prostatic apex) on the cystectomy specimen is performed to exclude tumor involvement. If there is no evidence of tumor, orthotopic reconstruction may be performed. If there is tumor at the prostatic apex, the urethral stump can be excised or a total urethrectomy may be performed at this time to obtain a negative margin, and a cutaneous diversion constructed.
  18. 18. Preservation of the Urethra in the Female Patient • A standard female cystectomy includes removal of the uterus, cervix, and ovaries (anterior exenteration). However, in selected females with clinically lower-stage disease, a number of authors have advocated preservation of the uterus and ovaries. • Whether the uterus is removed or not, whenever possible the bladder is dissected completely off the anterior vaginal wall rather than excising it. However, a deeply invasive tumor on the posterior bladder or trigone may necessitate excision of a portion of the anterior vaginal wall.
  19. 19. • A patient with a significant tumor at the bladder neck or with palpable extension into the vaginal wall is a poor candidate for neobladder and should undergo en bloc urethrectomy and cutaneous diversion.
  20. 20. • Preparation of the female urethra for an orthotopic neobladder. The fatty tissue overlying the anterior urethra is swept off the endopelvic fascia and the vesicourethral junction is carefully identified by positioning the Foley catheter at the bladder neck. Note that the endopelvic fascia and periurethral tissue anteriorly are not disturbed.
  21. 21. • Regardless of the form of vaginal reconstruction, a well-vascularized omental pedicle graft should be placed between the reconstructed vagina and the neobladder and secured to the endopelvic fascia at either side of the urethral stump to separate the suture lines and prevent fistula formation between the vaginal and urethral anastomosis, which may help support the pouch posteriorly.
  22. 22. TECHNIQUES FOR ORTHOTOPIC BLADDER SUBSTITUTION • Choice of Bowel Segment • excellent functional and clinical outcomes with voiding can be achieved regardless of the segment of bowel chosen as long as the principles of preservation of the rhabdosphincter as a continence mechanism and construction of an adequate capacity, low-pressure reservoir are maintained • Reservoirs made of detubularized ileum or ileum and colon together appear to have the greatest compliance and lowest likelihood of generating intermittent high-pressure contractions.
  23. 23. • The primary disadvantage of using distal ileum lies in the potential loss of absorption of vitamin B12. • Isolation of the segment of bowel to be used for the diversion must be performed carefully to preserve blood supply to the pouch, as well as to the bowel anastomosis. Need to Prevent Reflux: • It is clear that any mechanism introduced to prevent reflux may also potentially cause upper tract obstruction.
  24. 24. General Perioperative Management • Ileal Reservoirs • ileal reservoirs use from 60 to 75 cm of terminal ileum, which is detubularized and folded in a variety of ways to attempt to create a spheric shape. • The use of nonabsorbable suture and metal staples should be avoided because of the potential for stone formation. • two most popular configurations around the world are the Hautmann W-neobladder (and its various modifications) and the Studer pouch neobladder.
  25. 25. Camey II • The Camey II orthotopic substitute is a modification of the original Camey bladder substitute, which was a simple segment of ileum anastomosed to the ureters and urethra. • The modification includes detubularization and folding to eliminate peristaltic activity. • A fingertip opening is made in the preselected area for the ileourethral anastomosis, the entire ileal plate is brought down to the pelvis, and the urethral anastomosis is performed.
  26. 26. Ileal Neobladder (Hautmann Pouch) • This neobladder is an intentionally large-capacity, spheric (W configuration) ileal reservoir that is constructed in an attempt to optimize initial volume and potentially reduce nighttime incontinence.
  27. 27. Construction of the Studer neobladder (modified). • Designated segments of terminal ileum for construction of the orthotopic Studer pouch ileal neobladder. Note that the distal mesenteric division is made between the ileocolic and terminal branches of the superior mesenteric artery, which extends into the avascular plane of the mesentery. In addition, a small window of mesentery and a 5-cm segment of proximal small bowel are discarded to allow mobility to the pouch and small bowel anastomosis.
  28. 28. • The Studer pouch is constructed from an isolated 44-cm ileal segment (placed in an inverted U configuration), which forms the reservoir portion of the pouch, and a proximal 15-cm segment of ileum to form the afferent limb. The two 22-cm ileal segments are opened 2 cm adjacent to the mesentery beginning at the apex and carried upward to the ostium of the afferent segment.
  29. 29. • The previously incised ileal mucosa is then oversewn with two layers of a running 3-0 polyglycolic acid suture starting at the apex and running upward to the afferent limb. The reservoir is then closed by folding it in half in the opposite direction to which it was opened.
  30. 30. • Construction of the antireflux mechanism in the T pouch. The ileum is divided between the proximal afferent ileal segment and the 44-cm segment. The dotted line depicts the incision line on the U limbs. Mesenteric windows of Deaver are opened between the vascular arcades adjacent to the serosa. Placement of small Penrose drains through each mesenteric window helps facilitate passage of sutures. The distal 3 to 4 cm of the afferent ileal segment is anchored into a serosal-lined ileal trough formed by the base of the two adjacent 22-cm ileal segments, using 3-0 silk sutures.
  31. 31. • The previously anchored distal 3- to 4-cm afferent ileal segment is tapered over a 30-Fr catheter on the antimesenteric border. The incision of the bowel provides wide flaps of ileum that covers the tapered distal afferent ileal segment to form the antireflux mechanism in a flap-valve technique.
  32. 32. • A mucosa-to mucosa anastomosis is performed between the ostium of the afferent segment and the edges of the ileal flaps using interrupted 3-0 polyglycolic acid suture. The mucosal edges of the ileal flaps are brought over the tapered distal portion of the afferent ileal segment and sewn using a continuous 3-0 polyglycolic acid suture.
  33. 33. • Once the reservoir is folded in half, the anterior wall is closed with a two-layer 3-0 polyglycolic acid suture that is watertight. Note that the anterior suture line is stopped just short of the (patient) right side to allow insertion of an index finger, which will become the neobladder neck. Conversely a new buttonhole can be created at the most dependent portion of the pouch.
  34. 34. • Each ureter is spatulated and a standard bilateral end-to-side ureteroileal anastomosis is performed using interrupted 4- 0 polyglycolic acid suture.
  35. 35. • The reservoir is anastomosed to the urethra using the previously placed urethral sutures.
  36. 36. Colon and Ileocolic Pouches Orthotopic Mainz Pouch (Mainz III)
  37. 37. Le Bag Pouch
  38. 38. • late complications with the ileal conduit such as • peristomal hernia • stomal stenosis • pyelonephritis • kidney stones • ureteral obstruction • renal deterioration became more apparent with longer follow-up
  39. 39. • These clinical sequelae • the high-pressure reflux of infected urine or • obstruction of the upper urinary tract. • It was postulated that the addition of an antireflux technique to a conduit form of diversion could help diminish the problems of reflux and renal deterioration in these patients. • Unfortunately, with longer follow-up, similar complications with nonrefluxing colon conduits were observed.
  40. 40. • One of the earliest continent cutaneous diversions in humans was described by Gilchrist and colleagues in 1950. • This form of urinary reconstruction incorporated a cecal reservoir with the ileocecal valve as the continence mechanism and the distal ileum as a catheterizable stoma. • The concept of a continent cutaneous diversion was subsequently reintroduced by Kock and colleagues in 1982 with a technique that was originally developed for a continent ileostomy after colectomy for inflammatory bowel disease. • It incorporated an intussuscepted nipple valve to maintain continence and avoid reflux. In animal experiments and then in humans, Kock demonstrated the importance of complete detubularization of the bowel segment and the double-folding technique that creates the most spheric shape possible.
  41. 41. • After Kock described his results in his initial 12 patients, Skinner began performing this diversion in adults undergoing cystectomy for bladder cancer in 1982. • Although this form of urinary diversion required catheterization of an abdominal stoma, it eliminated the need for an external urostomy appliance. • The biggest challenge in the development of continent cutaneous diversion has been the design of a reliable, durable, efferent continence mechanism that is easily catheterizable.
  42. 42. Problems • stones, • difficulty in catheterizing, • peristomal hernias, and • the development of leakage are potential problems with all of them, often necessitating open surgical revision • Today, several different reliable techniques are available to create a continent cutaneous urinary diversion, including the Indiana pouch and various other forms of right colon pouches. • These forms of diversion can potentially offer an advantage to patients over an ileal conduit, but these operations remain technically challenging and are not widely used.
  43. 43. Early and Late Complications Both early and late complications may also be influenced by other factors such as - prior radiation therapy, - diabetes, and - other comorbidities. - Late complications are also influenced by tumor recurrence and the use of adjuvant or salvage systemic chemotherapy or radiation, and these causes may be difficult to separate out from causes related to the surgery.
  44. 44. • Late complications not • directly related to the diversion include bowel obstruction, ventral • hernia, thrombotic events, and cardiovascular problems common • to patients in this age group.
  45. 45. • Ventral hernias are quite common and may be in part related to the need for increased abdominal pressure to empty the neobladder. The poor fascial strength associated with advanced age and smoking undoubtedly contributes to this risk as well.
  46. 46. • primary late complications of orthotopic diversion that are directly related to the diversion itself include • incontinence, • urinary tract infection, • ureteroileal or afferent limb obstruction, • urethral stricture, • upper tract and pouch stones, • vaginal fistula, and pouch rupture. • Other than incontinence, these complications tend to be less common in orthotopic diversion than in continent cutaneous diversion, and many if not most can be managed by endoscopic procedures and rarely require open surgical revision
  47. 47. • Pouch perforation is rare in continent diversion in general, especially in orthotopic diversion because outlet resistance is usually low. The risk may be increased in patients who have had previous radiation therapy. It is a potentially life-threatening complication when it occurs. • The direct end-to-side Leadbetter or the combined Wallace anastomoses with interrupted fine absorbable sutures have been shown to have the lowest risk of stricture, approximately 3% to 6%. Obstruction from an antireflux valve has been seen in both hemi- Kock pouches and in the extraserosal tunneled afferent limb of the T pouch
  48. 48. • CT scans will often be misinterpreted by radiologists or urologists unfamiliar with the anatomy and/or the specific type of neobladder. • Pouch stones were very commonly seen in the Kock neobladder because of the use of surgical staples to maintain the intussuscepted nipple valve, with the incidence increasing steadily with time. Stones have been rare in the Studer and Hautmann neobladders, which are made entirely with absorbable suture.
  49. 49. • Pouch-vaginal fistula is a unique complication of orthotopic neobladder in women that can be quite difficult to repair. • Prevention methods include • leaving the vagina intact whenever it is safe from an oncologic standpoint, • careful watertight closure of the vaginal cuff when it is opened, and • placement of an omental flap between the vagina and neobladder, secured to the perivaginal tissue on either side of the urethral anastomosis
  50. 50. Incontinence: • The evaluation and management of urinary incontinence after orthotopic diversion should be delayed until the neobladder has had time to expand.
  51. 51. Follow up: NO CONSENSUS • Early evaluation (first 4 months) to identify early ureteroileal anastomotic strictures caused by technical difficulties or poorly vascularized distal ureters. • Middle period (4 months to 3 years) primarily focused on detecting cancer recurrence. This is best managed with CT or other cross-sectional imaging, which also allows evaluation of the upper tracts and reservoir for stones or obstruction • The frequency of the follow-up can be risk-adapted according to the pathologic findings at the time of cystectomy and the risk of subsequent recurrence. • Long-term follow-up (beyond 3 years) to detect pouch stones, late upper tract obstruction, and urothelial carcinoma arising in the urethra or upper tracts.
  52. 52. QUALITY OF LIFE AFTER URINARY DIVERSION • Most quality-of-life studies that have evaluated and compared patients undergoing various forms of urinary diversion have been criticized for methodologic problems that limit their conclusions. • The current body of published literature is insufficient to conclude that any form of urinary diversion is superior to another on the basis of health-related quality of life outcomes.
  53. 53. •Thank You
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