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Surgery Illustrated
ORTHOTOPIC ILEAL NEOBLADDER
U.E. STUDER
ET AL.
Surgical Atlas
Orthotopic ileal neobladder
U.E. STUDER, C. VAROL and H. DANUSER
University of Bern, Department of Urology, Bern, Switzerland
© 2 0 0 4 B J U I N T E R N A T I O N A L | 9 3 , 1 8 3 – 1 9 3 | doi:10.1046/j.1464-410X.2004.04641.x 183
U . E . S T U D E R ET AL.
The planning and preparation checklist • Adequate liver function • Good continence status
include: • Adequate bowel function • Deep vein thrombosis prophylaxis
• Antibiotic prophylaxis
• Patient agreement to indefinite follow-up • No tumour in the distal urethra, • Hyperextended supine position
• Adequate mental state, dexterity and paracollicular(male) or bladder neck (female)
mobility region
• A serum creatinine level of <150 mmol/L
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POSTOPERATIVE CARE treatment (2–6 g/day) which can be stopped feedback from the examiner about the
2–6 weeks later. A salt–losing syndrome adequacy of the contraction and is
The suprapubic and transurethral catheters by the bladder substitute can cause subsequently ensured of satisfactorily
need to be flushed and aspirated with saline hypovolaemia, dehydration and a loss of body training the sphincter in the future. This
0.9% every 6 h to prevent any catheter weight. Patients should therefore consume comprises contraction 10 times/h,
blockages which may lead to rupture of the 2–3 L of fluids per day, which is supplemented maintaining the contraction for 6 s and
bladder substitute. This risk is highest when with increased salt intake in their diet; body continued daily once continence is achieved.
bowel activity returns and the transurethral weight should also be monitored daily.
catheter is still in-situ. DIFFICULTIES
Voiding occurs initially while seated, every 2 h
Total parenteral nutrition is commenced on during the day and 3-h with the help of an The most challenging patients for a bladder
the first day and stopped as soon as oral alarm clock at night. Voiding occurs by substitution are those who are short and
intake is established. To prevent abdominal relaxing the pelvic floor, followed by slight obese, with a narrow pelvis. In these cases the
bloating and assist bowel function, abdominal straining. This is aided by hand mesentery of the ileum that is being used for
parasympathomimetic medications (e.g. pressure on the lower abdomen and bending the bladder substitute is thick. Folding the
neostigmine methylsulphate 3–6 ¥ 0.5 mg forwards. In-out catheterization is used once, ileal segment into a sphere can be difficult,
subcutaneously) is started 3 days after together with suprapubic ultrasonography, but it is always possible. As the mesentery is
surgery. The exteriorized ureteric catheters and later the postvoid residual volume is also short in these patients the distance
can also be manually irrigated if there is checked only by ultrasonography. Any UTI or between the reservoir and the urethra can be
suspected blockage and ureteric obstruction. bacteriuria is treated. The voiding interval is longer than expected. To gain length and
The ureteric catheters are removed increased stepwise from 2 to 4 h, in hourly achieve a tension-free anastomosis, ensure
sequentially at 5–8 days after surgery. steps, provided the findings from blood gas that the distal mesentery is maximally incised
analysis are compensated. The patient has to without jeopardising any blood supply to the
Exclusion of a leak with a pouchogram at prolong the interval to passively increase reservoir or the ileum. Careful superficial
8–10 days allows removal of the suprapubic bladder capacity to a desired volume of incisions (perpendicular to the mesenteric
catheter. This is followed 48 h later by the 500 mL even if incontinent. With an increase blood vessels) of the reservoir's mesenteric
urethral catheter, allowing for the puncture in reservoir capacity it is easier for the patient peritoneal surface will result in further
site from the suprapubic catheter in the to achieve continence. Laplace's law (pressure lengthening. It is important to move the
bladder substitution to seal. = tension/radius) states that the intravesical sigmoid colon or small bowel loops that may
pressure will decrease with an increase in be present between the mesoileum of the
After catheter removal, the patient is at reservoir radius, resulting in a low-pressure reservoir and the sacral promontory before
increased risk of a metabolic acidosis. Patients system. bringing the reservoir down to the urethra.
will complain of lethargy, fatigue, nausea, The patient can also be straightened or
vomiting and anorexia associated with The time to recovering continence depends on slightly flexed at the pelvis to reduce the
epigastric burning. The acidosis is monitored surgical technique, with nerve preservation to distance between the urethra and reservoir. To
using the base excess estimated by venous the urethra and pelvic floor, good counselling remove any tension on the reservoir-urethral
blood gas analysis, initially every 2–3 days with daily vigilant sphincter training, and the anastomosis, two sutures between the
and later at greater intervals, depending on age of the patient. Effective sphincter training reservoir and the pelvic floor can be placed
the blood gas values. The base excess needs to is taught by using a digital rectal examination lateral to the anastomosis. It should always be
be corrected if it is negative. Virtually all and helping the patient to contract only the possible to construct a tension-free reservoir-
patients will require sodium bicarbonate anal sphincter. The patient receives direct urethral anastomosis.
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