Continence after Total Bladder Replacement: Urodynamic Analysis of the Ileal Neobladder

Abstract

Since April 1986 we have carried out 103 bladder substitutions with the ileal neobladder; 91 of these were performed after radical cystectomy in males (group 1) and 12 after subtotal bladder resection (group 2); 55 patients in group 1 and 8 in group 2 were followed up by long-term urodynamic investigations and by a questionnaire concerning micturition patterns and continence at home 3 months post-operatively. The maximum bladder capacity was approximately 770 ml with an absolute intravesical pressure of 23 to 30 cm H2O. Intravesical pressure waves with a mean amplitude of 20 cm H2O were found in 38% of patients in group 1 and 25% in group 2; 61% of these patients were asymptomatic. The results showed that 85% of patients were continent by day and by night. We attribute this to our operative technique: the ileal loop is folded 4 times in a "W" or "M" shape to achieve complete detubularisation of the bowel and the external urethral sphincter is carefully preserved. Altogether, these data show the ileal neobladder technique to be a reliable and safe method of bladder substitution.

The impact of prior prostatic surgery on urinary continence in patients undergoing orthotopic ileal neobladder

“…In the present study 54/62 (79.1%) of the patients have diurnal continence according to our criteria and these figures were comparable to other published series where postoperative urinary continence ranged from 60% to 96% (1,3,5,(7)(8)(9). In order to maintain erectile function and urinary continence, Schlling & Friesen (10) since 1987, had already been made routine diagnostic staging of the cancer with transurethral resection of the prostate to permit a transprostatic selective cystectomy with an ileal bladder, cutting through the apex of the prostate thus, leaving a wide funnel-shaped tunnel of the prostatic urethra, for the anastomosis with the M or W shaped ileal reservoir.…”

“…In the last 10 to 15 years, significant surgical advances have been reached for urinary diversion following radical cystectomy, leading to an increased number of patients that have been subjected to an orthotopic ileal neobladder. As the result of improved clinical staging, earlier patient acceptance for radical surgery and improved postoperative support, there has been a significant decrease in the morbidity and mortality of these cases (1,2) According to the pioneer work of Le Duc & Camey (2), the principle of bladder replacement with ileum and the preservation of the distal urethral sphincter allowing urinary continence have shown to be technically feasible with an acceptable level of morbidity (3). Also, the principle of bowel detubularization used in the ileal Kock pouch (4) led to an improvement in the capacity/pressure ratio of the ileal reservoirs, making the technique more efficient and popularizing its use.…”

Modified S-Ileal Neobladder for Continent Urinary Diversion: Functional and Urodynamic Results after 20 Years of Follow-Up

“…Continence is dependent upon an intact urethral sphincteric mechanism as well as a compliant, low-pressure reservoir neobladder of adequate capacity [9]. Changes in the preserved urethral sphincter mechanism can be incurred by either iatrogenic destruction of the sphincter unit or by the loss of vesicourethral reflexes after cystoprostatectomy, both resulting in stress urinary incontinence [10]. Intricate nerve-sparing dissection of the periurethral tissues ensures preservation of the distal sphincter mechanism and was performed in all of our cases.…”

Instability in the augmented bladder

“…M o s t o f the recent reports on b l a d d e r replacement [2] or a u g m e n t a t i o n [3,4,7,10,11] mention a small n u m b e r of patients whose incontinence persists postoperatively, often at night. "Phasic contractions", pressure waves o f 2 0 -4 0 cm H 2 0 or "persistent instability" were described in these papers.…”