A candidate for an ileal neobladder after radical cystectomy must meet specific criteria related to their overall health, anatomy, and medical history. Individuals who may not be suitable for an ileal neobladder (contraindications) include those with significant renal impairment, compromised liver function, or poor overall health due to age or comorbidities.

Patients with a history of bowel disease, previous pelvic radiation, or cancer that has invaded surrounding organs may also be excluded. Additionally, those who lack the physical or cognitive ability to manage the complex postoperative care required for a neobladder are typically not candidates.

Who is not candidate for ileal neobladder after radical cystectomy?

Artificial bladder is usually performed in cases where the bladder is removed due to bladder cancer. Additionally, it is performed in cases where the bladder needs to be removed due to various diseases. Here, a bladder is created from a section of intestine taken from the small intestine, usually called the ileum, and this newly made bladder is placed in place of the normal bladder. This method is called “orthotopic artificial bladder surgery”.

In recent years, interest in ileal orthothopic neobladder surgery after radical cystectomy due to bladder cancer has increased. The reason for this is that the quality of life in postoperative patients is much better than other methods (ileal loop, urine coming into a bag attached to the abdomen).

We have been performing this surgery successfully for a long time. It should not be forgotten that this surgery is not suitable for everyone. It is necessary to select the patient very carefully. It should not be forgotten that “the most important goal in cancer surgery is to completely remove the cancer with the least side effects, if possible.” Otherwise, cancer recurrence and problems in the use of the neobladder may occur.

An ileal neobladder may not be suitable for patients who have:

• Impaired Kidney Function: Reduced renal function can complicate the body’s ability to manage the changes in urinary system dynamics after surgery.
• Severe Comorbidities: Significant health issues such as cardiovascular disease, poor liver function, or respiratory problems may increase surgical risks and impact recovery.
• Previous Pelvic Radiation: Prior radiation therapy to the pelvis can affect the tissues needed to create a neobladder and may lead to complications.
• Advanced Age or Frailty: Older patients or those with reduced physical resilience may struggle with the demands of recovery and self-care.
• Bowel Disease: Conditions like Crohn’s disease or ulcerative colitis can affect the bowel’s suitability for constructing a neobladder.
• Cancer Invasion of Surrounding Organs: If the cancer has spread to adjacent organs, a neobladder may not be feasible.
• Inability to Manage Postoperative Care: Patients who cannot commit to or manage the complex postoperative care required, including those with cognitive impairments, may not be candidates.
• People with problems in their hands and spinal cord injury: Patients who have undergone artificial bladder surgery may sometimes have the problem of not being able to urinate. In such cases, patients must perform self-catheterization. In this way, the bladder is emptied. For this, patients must not have any use defects or injuries in their hands and fingers.
• People with pathology in the urethra: One of the conditions that must be taken into consideration in placing the newly constructed bladder in its normal place is that the urethra is normal. Otherwise, there may be problems in the urine flowing from its normal anatomical place. If there is urethral stenosis and it can be corrected surgically, this must also be corrected.
• Patients with external sphincter insufficiency: The external sphincter is a structure that is very important in urine retention. If an artificial bladder is used in patients with problems in this area and urinary incontinence, urinary incontinence will occur. However, if the patient is suitable, this situation is corrected by installing a sphincter. Thanks to the sphincter, patients are prevented from leaking urine.
• Short intestinal mesentery: The mesentery is the fatty tissue through which the vessels feeding the intestines pass.  Sometimes the mesentery of the intestine to be removed for the artificial bladder is too short and in this case, an artificial bladder cannot be made. If forced, malnutrition may occur. This situation usually occurs in fat and short people.
• If there is cancer in the urethra: This surgery should not be performed if there is cancer in the urethra. Because recurrence occurs here after surgery.
• If there is cancer in the prostate apex: If there is cancer in the prostate apex (where the prostate meets the upper part of the urethra) in men, then artificial bladder surgery is not performed. If it is done, the recurrence rate is high in the future.
• If there is cancer in the bladder neck in women: If the cancer has affected the bladder neck in female patients, this surgery is not suitable for these people as it will recur.
• If there is metastasis: If the cancer has spread outside the bladder, that is, if there is metastasis, this surgery is not performed in such cases.
• Patient compliance and mental capacity: This surgery is suitable for individuals who can come to regular check-ups, understand possible complications, are compatible and have sufficient intellectual capacity.
• Impairment in liver functions: This surgery is not suitable for people with serious liver problems.

These factors help determine whether a patient is an appropriate candidate for an ileal neobladder after radical cystectomy.

Summary

Patients who may not be candidates for an ileal neobladder after radical cystectomy include those with impaired kidney function, severe comorbidities, previous pelvic radiation, advanced age or frailty, bowel disease, cancer invasion into surrounding organs, or an inability to manage the required postoperative care. Before deciding to perform this surgery, a detailed evaluation should be made and the most appropriate treatment for the patient should be applied.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE