LETTER TO THE EDITOR
Re: Gynecologic-tract sparing extra peritoneal retrograde radical cystectomy with neobladder
Jagdeesh N. Kulkarni; S. Jamal Rizvi; U. Purushotthama Acharya; K. S. Shiva Kumar; P. Tiwari
Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, India
Int Braz J Urol, 34: 180-190, 2008
To the Editor:
Bladder cancer is considered the most prevalent malignant tumor affecting male in Egypt. Orthotopic ileal neobladder is currently the preferred continent urinary diversion in suitable patients undergoing radical cystectomy for muscle-invasive bladder cancer and may be considered the gold standard with which other forms of diversion are compared. Incorporation of antireflux system in orthotopic ileal neobladder substitutes is important in protecting the upper urinary tract in all patients undergoing continent diversion with a reasonable life expectancy. If this were not important, why is it that normal human bladder anatomy has evolved with an effective antireflux mechanism? Indeed, many antireflux techniques have been developed but the multiplicity of these techniques suggests that an ideal solution has not been found. All antireflux anastmosis have an inherent risk of functional failure (1).
Patients with carcinoma in situ of the prostatic urethra, tumors near bladder neck or infiltrating the prostate, multifocal papillary tumors, history of upper tract tumors or positive margins on frozen section of the transected proximal urethra must be excluded. For these patients, continent cutaneous diversion using the same technique will be evolved soon. After radical cystectomy in females, both ureters are intussuscepted in modified Sigma pouch but most of the females now prefer orthotopic ileal neobladder (2).
The new technique, which prevents reflux, has several advantages compared with antireflux techniques: technical simplicity and the procedure is suitable for all types of ureters including normal, dilated, short and irradiated ureters. It allows a non obstructed unidirectional flow of urine with minimal rate of stenosis and/or surgical revision so; it can protect the upper urinary tract. The use of foreign material like staples or meshes is avoided and the antireflux system is constructed from a minimal length of bowel segment decreasing metabolic complications associated with malabsorption or resorption. The afferent short limb provides extra length to reach the ureter, a tension free anastomosis, no risks of ureteral angulation with neobladder filling, and the possibility to resect the ureter far above the bladder, thus avoiding ureteral ischemia and distal recurrence. With intermediate follow up the S pouch ileal neobladder incorporating the new antireflux technique appears to be effective in preventing reflux of urine without significantly increasing the incidence of obstruction. The clinical and functional results of S pouch ileal neobladder appear to be accepted. Despite these encouraging results prolonged follow up will be required to determine the durability and long term complications associated with orthotopic ileal neobladder.
Dr. Adel Denewer
Department of Surgical Oncology
Oncology Center, Mansoura University
Mansoura, Egypt
E-mail: adeldenewer@mans.edu.eg
- 1. Hautmann RE: Urinary diversion: ileal conduit to neobladder. J Urol. 2003; 169: 834-42.
- 2. Denewer A: A low-pressure rectosigmoid pouch created by side-to-side anastomosis with a stapling technique and sigmoid colon intussusception as an antireflux procedure. Br J Urol. 1998; 81: 856-61.
Publication Dates
-
Publication in this collection
23 Sept 2008 -
Date of issue
June 2008
