Orthotopic neobladder after cystectomy

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Who is offered a neobladder The patient having a radical cystectomy whose urethra can be kept: a negative urethral margin on frozen section, no tumour in the prostatic urethra or stroma in a man, no tumour at the bladder neck in a woman. Renal function good enough to handle the reabsorption, a creatinine under about 150 or an eGFR above 50, and normal liver function. No bowel disease that makes ileum unusable, no previous high-dose pelvic radiotherapy as a relative bar. And a motivated patient with the hands and the mind for it, who has heard and accepted that there will be leakage by day early and at night for good, that voiding is by the clock and by straining, and that they may have to catheterise themselves, women more often than men.
2. The ileal segment With the cystectomy and node dissection complete and the urethral stump prepared, the terminal ileum is delivered. A segment of fifty-five to sixty centimetres is measured with a tape along the antimesenteric border, its distal end fifteen to twenty centimetres proximal to the ileocaecal valve, sparing the last ileum for B12 and bile salts. The mesentery is transilluminated and the segment taken on its arcades, the mesentery divided between windows only as far as is needed for the loop to reach the urethra without tension, the proximal division deeper than the distal because the proximal end has to reach the pelvis last. Continuity is restored above the segment with a stapled side-to-side anastomosis and the mesenteric window closed. The loop is irrigated until clear.
   where it bites: the deepest point of the pouch has to reach the membranous urethra; a mesentery that is short here is a tensioned anastomosis and a stricture.
3. Detubularising, except the afferent limb The proximal ten to fifteen centimetres of the segment is left intact as a tube: this is the afferent limb into which the ureters will be joined, and it stays isoperistaltic, carrying urine toward the pouch and giving a soft antireflux effect. The remaining forty to forty-five centimetres is opened along the antimesenteric border with the diathermy from the distal staple line up to the base of the limb, so that it lies as a long plate with its mesentery entering from behind. The reason is the same as in any reservoir: a tube of ileum contracts as a ring and makes pressure, an opened plate cannot. Bleeding from the edge is taken with the bipolar and the mucosa is wiped of mucus.
4. Folding and sewing the sphere The opened plate is folded on itself into a U, the two limbs side by side, and the adjacent edges are sewn together with a running 3-0 Vicryl or PDS, mucosa to mucosa, from the fold outward. The plate is then folded a second time, at right angles to the first, and the remaining edges closed in the same way so that a sphere forms, the Studer principle: by Laplace, a large radius stores a large volume at a low pressure, and the double fold breaks every line of ileum that could contract as a unit. The afferent limb rises from the top of the sphere. Before it is closed the most dependent point of the pouch is chosen, where a finger drops to the urethra without pull, and marked.
   where it bites: a pouch whose lowest point does not drop onto the urethra without tension will be pulled up by its mesentery; choose the dependent point before the sphere is closed.
5. The ureters into the afferent limb The left ureter is brought under the sigmoid mesentery through a generous window and both ureters are spatulated for fifteen to twenty millimetres on their lateral wall with the adventitia kept. Each is implanted end-to-side into the afferent limb, Bricker fashion, through a small enterotomy, mucosa to mucosa with interrupted 4-0 or 5-0 PDS, over a 6 or 7 French single-J stent passed up to the renal pelvis; a Wallace plate into the open end of the limb is the alternative. The stents are led down through the limb into the pouch. The join is refluxing by design: the afferent limb and the low pressure of the sphere protect the kidneys, and a tunnelled antireflux implant strictures more often than it helps.
   where it bites: the ureteric blood supply runs in the adventitia, medial above the pelvic brim and lateral below it; a stripped or tensioned ureter strictures at the join.
6. The urethral anastomosis At the marked dependent point a small opening, the size of a fingertip, is made in the pouch, no larger, because a large opening funnels and kinks. The urethral stump was prepared at the cystectomy with five or six 2-0 or 3-0 Monocryl sutures placed through the membranous urethra and the sphincter and held on clips, at two, four, six, eight, ten and twelve o'clock. A 20 or 22 French silicone catheter is passed through the urethra into the pouch, the sutures are passed through the pouch opening from inside to out at the matching positions, the pouch is dropped down onto the urethra with the assistant relaxing the packs, and the sutures tied in turn from posterior to anterior, without tension. The catheter balloon is inflated in the pouch.
   where it bites: the sutures take the urethral stump and the sphincter with it; a bite carried into the pelvic floor beside the urethra costs continence.
7. Stents, drain and the catheter The stents come out through the pouch wall and the abdominal wall on the right, each fixed to the skin, or are led alongside the catheter. A tube drain is placed in the pelvis next to the anastomoses. The pouch is filled with 100 millilitres of saline through the catheter and every suture line inspected; a leak is closed with an interrupted suture. Omentum is brought down to the pelvis if it reaches. The abdomen is closed as a mass closure. The catheter is flushed with 50 millilitres of saline four to six times a day from the first day, because mucus blocks it and a blocked pouch tears its suture lines; it stays for about three weeks.
8. After: the cystogram, the clock, the night A pouchogram at about three weeks before the catheter comes out, and then retraining begins. The patient voids sitting, relaxing the pelvic floor and pressing on the abdomen, every two hours by day and by alarm every three at night, stretching the interval by an hour each fortnight until the pouch holds 400 to 500 millilitres. Daytime continence comes over months in most, nocturnal leakage persists in a third or more, because the pouch has no sensation and the sphincter relaxes in sleep. The residual is scanned at each review; a patient who does not empty catheterises, which is more often the woman. Bicarbonate, creatinine, B12 and the upper tracts are checked for life, and the urethra and upper tracts are under surveillance for recurrence.

Complications and immediate saves

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FRCS viva questions

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Evidence and guidance