The surgical technique and initial outcomes of Anatolian neobladder: a novel technique of ileal neobladder after radical cystectomy

Orthotopic neobladders are constructed for urinary diversion after radical cystectomy. An orthotopic neobladder should achieve several normal bladder characteristics, including a continence mechanism, adequate capacity at a low pressure, and an antireflux mechanism for preventing upper urinary tract dilatation [1].

Camey first described an orthotopic neobladder in which a small tubular bowel segment was used as a bladder substitute by anastomosing it directly to the urethra without detubularization [2]. Since this version was described, many different types of orthotopic neobladders have been described, consisting of different gastrointestinal segments [3–5]. Intestinal detubularization plays an important role in the formation of low pressure and adequate bladder volume. Based on this, various techniques have been acceptable using different types of bowel segments (ileum, ileo-colon, colon, sigmoid) and ureterointestinal anastomosis. Studer et al. reported use of a detubularized ileal pouch as a bladder substitute in patients with an intact urethra after cystectomy [6]. There is no agreement on the significant advantage of a single technique over another, despite the description of each technique by the investigators.

We present our experience with a new surgical technique for ileal neobladder creation using 45 cm of ileum. The neobladder is constructed in a simple triangular configuration without a chimney. A spherical apex segment forms the neourethra at the bottom, which provides a sufficient part for anastomosis. The surgical technique, perioperative complications, and medium-term results, including cancer control and continence, are described. The outcomes of were compared with patients who underwent standard neobladder in our center.

Various types of orthotopic neobladders are used as a method of urinary diversion after radical cystectomy. Although new neobladder techniques have been described, it is still controversial as to how best to shape it. A normal neobladder should be safe and easy to create. Ideally, it should have low pressure. It should also be of the appropriate capacity. There should be no reflux in the upper urinary tract and the development of stricture in the ureters should be prevented. In addition, day- and nighttime continence should be ensured [8]. The Studer neobladder and other ileo-colonic neobladder techniques which are known for long term outcomes are the most frequently performed methods [5, 6, 9–11]. The Studer technique has these characteristics and has significant advantages [6]. Generally, surgeons adopt one or two techniques that are suitable for them. As surgeons perform a significant number of these reconstructive techniques per year, it is reasonable for them to adopt a technique that is appropriate, easy to perform and long-term results are known. Our clinic is a high volume center for radical cystectomy (> 25) and a mean of 30 patients underwent this operation within a year. These reasons prompted us to design a new neobladder construction. In our novel technique, the operative time is acceptable. The main advantage of this technique is that a simple shape, like an original bladder configuration, is constructed. The ileal segment used for the ureteroileal anastomosis is formed spontaneously and the ureters are anastomosed to the bottom of the neobladder without creating a chimney (Fig. 7). Residual urine volume was not significant in patients due to the bladder configuration. In the Anatolian neobladder, we fixed both upper corners of the ileal pouch to the psoas muscles. In our opinion, this was another factor that led to good emptying of the neobladder.

The ureters were anastomosed to the neobladder according to the technique of Abol-Eneim and Ghoneim [12]. We anastomosed the spatulated end of the ureters to the intestinal mucosa using a direct mucosa-to-mucosa and inverted ureteral nipple technique. Use of an isoperistaltic limb of ileum as an antireflux mechanism offers the advantage of an easily constructed ureterointestinal anastomosis with a low incidence of reflux and confusion of the upper tracts. To date, of 72 renal units, there is no confusion of any renal unit. This rate of upper tract preservation is acceptable. Before removing the Foley catheters postoperatively, we routinely perform cystography to demonstrate no reflux in the renal units.

There were no severe intraoperative complications in our study. Mean blood loss was 550 mL (range, 350–1700) and 580 mL (300–1800 mL), for novel technique and standard technique, respectively and there were no statistically significant differences between two techniques (P = 0.22). Protection of the upper urinary tract is a critical point during orthotopic neobladder reconstructions. In our study, urinary infection occurred in eight patients (22.2%), all of whom improved with medical treatment. Rogers and Scardino used a modification of the Studer technique and reported acute pyelonephritis in two of 20 patients (10%) [13]. In another study, Yoneda et al. used a modified Studer technique and reported acute pyelonephritis in 27% of the patients [14]. Our series had a similar rate of pyelonephritis and there was no statistically difference for postoperative urinary infection rates between novel technique and standard neobladder in this study. Paralytic ileus occurred in three patients (8.3%) for novel technique and in 1 (6.2%) for standard neobladder, but open surgery was not required in any patient. Incisional hernia in one patient required additional surgery. No other late complications occurred. Stenosis of the uretero-neobladder anastomosis in one patient (2.7%) for novel technique and 1 patient for standard technique (6.2%), were treated by additional open surgery. Ureterointestinal anastomosis should prevent stenosis and obstruction [15]. Stenosis of the urethra in one patient (2.7%) for novel technique and 1 patient (6.2%) for standard technique, were treated endoscopically. Authors should remember that the rate of complications after radical cystectomy and orthotopic urinary diversion is not to be underestimated. In the review published by Faba et al., they stated that the complications were significant after cystectomy and orthotopic urinary diversion and they were not as low as in previous publications [16]. It was emphasized that complications were encountered in the 20th year after the operation and therefore follow-up should be done.

In our study, there were no metabolic complications. Use of the terminal ileum was not advocated because of the potential risk of vitamin B12 and bile acid malabsorption, and resultant diarrhea [17]. Exclusion of the ileocecal valve from the normal alimentary tract and interference with feces transit time also may account for diarrhea in these patients. There are several reports of metabolic acidosis occurring in patients during follow-up [5, 6]. Hautmann et al. reported that 48% of patients with an ileal neobladder required alkalizing treatment for acidotic imbalance [5]. Gakis et al. described the advantages of using a terminal ileal segment for orthotopic urinary diversion [17]. Metabolic consequences due to bowel wall secretion and urinary reabsorption from the intestinal reservoir can be compensated best in the terminal ileum or jejunum. As a result, the terminal ileal segment is the most ideally suited bowel segment for orthotopic urinary diversion. There were no metabolic complications in our patients during the early follow-up period. We routinely evaluated laboratory values and replaced vitamin B and sodium bicarbonate if necessary during long-term follow-up.

Complete daytime continence was achieved in 32 of the 36 patients (88.8%) and 14 of the 16 patients (87.5%) for novel technique and standard technique, respectively (p = 0.89). Also, nighttime continence was achieved in 20 (55.5%) and 9 (56.2%) patients, for novel technique and standard technique, respectively (p = 0.96) and there was no statistically significant difference between two techniques. Parekh et al. reported that patients with bladder substitution achieved daytime control more rapidly than those who underwent radical prostatectomy, and stress urinary incontinence was rare [18]. Also, patient adaptation and mental capacity to understand the new bladder are important factors for achieving continence. Our success rate for achieving continence was similar to that of other studies [5, 6, 13, 15]. In addition, there was no statistically difference between our novel technique and standard technique in this study.

Finally, the complication rate was acceptable, and there was no perioperative mortality for novel technique and standard technique, in this study. In addition, this bladder substitute of novel technique appears to be technically easier and safe. However, there are several limitations to our study. One limitation was that our data were collected retrospectively. Consecutively, 36 patients were included in this study and compared with 16 patients who underwent standard neobladder. However, the number of patients was limited and long-term results were not known. This might have decreased the power of the study. However, the functional results and postoperative morbidity rates in our series were acceptable. Future studies including larger series of patients should be designed prospectively to overcome existing limitations.

Our study demonstrated the feasibility of novel technique (Anatolian neobladder) in the treatment of bladder cancer after radical cystectomy. It can be an alternative to other ileal neobladder techniques. Further prospective and randomized controlled comparative studies including large series of patients are needed.