Orthotopic bladder reconstruction is a surgical procedure performed after radical cystectomy, the removal of the bladder, commonly due to bladder cancer. This technique involves creating a new bladder within the body, typically using a segment of the small intestine.

The primary aim is to restore normal urinary function, allowing patients to void through the natural urethra. Orthotopic bladder reconstruction offers advantages such as improved continence, enhanced body image, and a more natural urinary experience. It involves careful patient selection, precise surgical techniques, and ongoing postoperative care for successful outcomes.

Radical cystectomy and ortothopic bladder

Orthotopic bladder reconstruction after radical cystectomy is a surgical procedure aimed at creating a new bladder within the patient’s body following the removal of the original bladder due to conditions such as bladder cancer. This complex surgical technique is designed to improve the patient’s quality of life by restoring normal urinary function while minimizing the impact on their overall well-being.

Here’s an introduction to orthotopic bladder reconstruction after radical cystectomy:

• Radical Cystectomy:

• This surgical procedure involves the complete removal of the bladder, often due to bladder cancer that has invaded the muscle wall or for other advanced conditions. In some cases, nearby organs such as the prostate or uterus may also be removed.

• Need for Reconstruction:

• After radical cystectomy, a urinary diversion is necessary to redirect the flow of urine from the kidneys to the outside of the body. Orthotopic bladder reconstruction is one option for urinary diversion.

• Orthotopic Bladder Reconstruction:

• Unlike other urinary diversion methods that involve creating an external pouch (ileal conduit or continent cutaneous reservoir), orthotopic bladder reconstruction aims to fashion a neobladder inside the patient’s pelvis using a segment of the small intestine (usually the ileum).
  • The neobladder is designed to replicate the normal bladder in terms of both anatomy and function, allowing the patient to void urine through the natural urethral passage.

• Surgical Technique:

• The surgeon uses a section of the small intestine to create a reservoir that will function as the new bladder. The specific technique may vary, but common methods include the Studer pouch or the Hautmann pouch.

• Functional Outcome:

• One of the key advantages of orthotopic bladder reconstruction is the preservation of natural voiding through the urethra. This can contribute to a better quality of life for the patient compared to other forms of urinary diversion.

• Postoperative Care:

• Recovery from orthotopic bladder reconstruction involves close monitoring for potential complications, such as infections or issues related to the surgical anastomosis. Patients may require a period of catheterization initially to allow the new bladder to heal.

• Long-Term Considerations:

• Patients who undergo orthotopic bladder reconstruction will need to adapt to a new way of voiding, and they may need to follow certain lifestyle adjustments. Regular follow-up appointments and monitoring for potential complications or recurrence of bladder cancer are crucial.

• Patient Selection:

• Not all patients are suitable candidates for orthotopic bladder reconstruction. Factors such as the extent of the disease, overall health, and the ability to comply with postoperative care and monitoring play a role in determining candidacy.

• Advancements in Technology:

• Ongoing research and advancements in surgical techniques and technologies continue to refine the procedure, aiming to enhance both the functional outcomes and the overall patient experience.

In conclusion, orthotopic bladder reconstruction after radical cystectomy is a sophisticated surgical option that seeks to provide patients with improved quality of life by restoring natural urinary function. The success of the procedure depends on various factors, including patient selection, surgical expertise, and postoperative care. As with any surgical procedure, the decision to undergo orthotopic bladder reconstruction should be made through careful consideration and consultation with a multidisciplinary medical team.

Is orthotopic bladder also suitable for women?

Yes, orthotopic bladder reconstruction can also be performed in women. While the majority of cases involve male patients due to the prevalence of bladder cancer, women who undergo radical cystectomy for conditions such as advanced bladder cancer may also be candidates for orthotopic bladder reconstruction.

The surgical technique for orthotopic bladder reconstruction in women is generally similar to that in men. The surgeon uses a section of the small intestine to create a neobladder, which is then connected to the urethra to restore normal urinary function. The procedure aims to provide women with the benefits of improved continence, enhanced body image, and a more natural urinary experience.

However, the decision to perform orthotopic bladder reconstruction in women depends on various factors, including the extent of the disease, the patient’s overall health, and individual considerations. The gynecological anatomy in women may present some unique challenges, but experienced urological surgeons can adapt the procedure to suit female patients.

As with any medical decision, the choice of urinary diversion method, including orthotopic bladder reconstruction, should be made in consultation with the patient’s healthcare team, considering the specific circumstances and preferences of the individual.

Advantages of ortothopic bladder after radical cytectomy due to bladder cancer

Orthotopic bladder reconstruction after radical cystectomy offers several advantages for patients compared to other forms of urinary diversion. Here are some of the key advantages:

• Improved Quality of Life:

• Orthotopic bladder reconstruction aims to preserve natural voiding through the urethra, allowing patients to maintain a sense of normalcy in urinary function. This can significantly contribute to an improved quality of life compared to alternative urinary diversion methods.

• Continence Preservation:

• Unlike some other diversion techniques that may require external appliances or catheters, orthotopic reconstruction often results in better urinary continence. Patients can achieve a more natural and socially acceptable voiding pattern without the need for external devices.

• Enhanced Body Image and Self-Esteem:

• The preservation of natural voiding and the absence of external pouches or appliances can positively impact body image and self-esteem. Patients may feel more comfortable and confident in social situations, as the surgical outcome is designed to be less conspicuous.

• Psychosocial Benefits:

• The ability to void through the natural urethra can reduce the psychological impact of urinary diversion. Patients may experience less stigma and psychological distress associated with managing an external appliance or urinary diversion that requires more complex care.

• Patient Satisfaction:

• Studies have suggested that patients who undergo orthotopic bladder reconstruction report higher satisfaction rates compared to those undergoing alternative diversion procedures. The ability to resume normal voiding can be a significant factor in patient contentment.

• Functional Mimicry of the Native Bladder:

• Orthotopic neobladders are designed to mimic the function of the natural bladder, allowing for more natural storage and emptying of urine. This functional similarity can contribute to a better overall urinary experience for patients.

• Reduced Impact on Sexual Function:

• Preserving the urethra and achieving a more natural voiding mechanism can contribute to the preservation of sexual function. This is an important consideration for many patients and can positively impact their overall postoperative experience.

• Decreased Risk of Metabolic Abnormalities:

• Some urinary diversion methods, such as ileal conduit, may be associated with a risk of metabolic abnormalities, including changes in electrolyte balance. Orthotopic bladder reconstruction may have a lower risk of such complications.

• Potential for Improved Social Integration:

• The ability to void in a manner similar to pre-surgery conditions can contribute to improved social integration. Patients may feel more at ease in various social settings without the need for external accessories or concerns about odor associated with certain types of diversions.

It’s important to note that the choice of urinary diversion method, including orthotopic bladder reconstruction, depends on various factors such as the patient’s overall health, the extent of the disease, and individual preferences. The decision should be made in consultation with a urological surgeon and a multidisciplinary medical team to ensure the most suitable approach for each patient’s specific circumstances.

Long term outcomes of ortothopic bladder after radical cytectomy

The long-term outcomes of orthotopic bladder reconstruction after radical cystectomy are generally positive, with many patients experiencing improved quality of life and successful adaptation to the neobladder. However, it’s important to note that individual experiences can vary, and long-term outcomes depend on various factors, including the patient’s overall health, the extent of the disease, and adherence to postoperative care.

Here are some key aspects of the long-term outcomes associated with orthotopic bladder reconstruction:

• Continence:

• Many patients achieve a good level of urinary continence after orthotopic bladder reconstruction. The neobladder is designed to store and empty urine in a manner that mimics the natural bladder, contributing to better continence outcomes.

• Quality of Life:

• Studies have shown that patients who undergo orthotopic bladder reconstruction report a favorable quality of life in the long term. The ability to void through the natural urethra and the absence of external appliances can positively impact psychological well-being and overall satisfaction.

• Functional Adaptation:

• Over time, patients tend to adapt well to the new bladder function. With proper postoperative care and rehabilitation, individuals can often resume normal activities and integrate the neobladder into their daily lives.

• Sexual Function:

• Preserving the urethra and achieving a more natural voiding mechanism may contribute to the preservation of sexual function. However, it’s essential to note that individual experiences can vary, and patients may need support or counseling to address any concerns related to sexual function.

• Complications and Follow-Up:

• Long-term follow-up care is crucial to monitor for potential complications and address any issues that may arise. Complications such as urinary tract infections, metabolic abnormalities, or neobladder-related concerns may be managed through regular check-ups and appropriate interventions.

• Recurrence of Bladder Cancer:

• The risk of bladder cancer recurrence remains a concern, and long-term follow-up includes surveillance to detect any signs of recurrence. Regular cystoscopy and imaging studies may be part of the monitoring process.

• Lifestyle Adjustments:

• Patients often need to make certain lifestyle adjustments, including managing fluid intake, maintaining regular voiding schedules, and possibly dealing with dietary considerations. Compliance with these adjustments can influence long-term outcomes.

• Patient Education and Support:

• Ongoing patient education and support are essential for long-term success. Providing resources, information, and support groups can help patients navigate the challenges associated with orthotopic bladder reconstruction and adapt to long-term changes.

It’s crucial for individuals who have undergone orthotopic bladder reconstruction to maintain regular follow-up appointments with their healthcare team. These appointments allow for the monitoring of long-term outcomes, early detection of potential issues, and ongoing support to optimize the patient’s overall well-being. The success of orthotopic bladder reconstruction in the long term is influenced by a collaborative approach involving the patient, urological surgeon, and a multidisciplinary healthcare team.

Summary of ortothopic bladder after radical cytectomy

Orthotopic bladder reconstruction after radical cystectomy is a surgical procedure designed to restore normal urinary function for individuals who have undergone the removal of the bladder, typically due to conditions such as bladder cancer. Here is a summary of key points related to orthotopic bladder reconstruction:

• Procedure Overview:

• Following radical cystectomy, which involves the removal of the bladder, orthotopic bladder reconstruction aims to create a new bladder within the patient’s body using a segment of the small intestine.

• Purpose:

• The primary goal of this procedure is to improve the patient’s quality of life by preserving natural voiding through the urethra, mimicking the function of the original bladder.

• Advantages:

• Compared to alternative urinary diversion methods, orthotopic reconstruction offers advantages such as improved continence, enhanced body image, better psychosocial well-being, and a more natural urinary experience.

• Surgical Technique:

• The surgeon typically uses a section of the small intestine, often the ileum, to create a neobladder. Common techniques include the Studer pouch or the Hautmann pouch.

• Functional Mimicry:

• The neobladder is designed to replicate the anatomical and functional aspects of the natural bladder, allowing for storage and periodic voiding of urine through the urethra.

• Postoperative Care:

• Patients require careful postoperative care, including monitoring for complications, adherence to lifestyle adjustments, and sometimes a period of catheterization for the neobladder to heal.

• Long-Term Outcomes:

• Long-term outcomes are generally positive, with many patients experiencing improved quality of life, continence, and successful adaptation to the neobladder. Regular follow-up appointments are essential for monitoring and addressing any issues that may arise.

• Considerations for Patient Selection:

• Not all patients are suitable candidates for orthotopic bladder reconstruction. Factors such as the extent of the disease, overall health, and the ability to comply with postoperative care and lifestyle adjustments play a role in determining candidacy.

• Risk of Bladder Cancer Recurrence:

• Despite the benefits, there is a continued risk of bladder cancer recurrence, necessitating regular surveillance through cystoscopy and imaging studies during long-term follow-up.

• Collaborative Approach:

• Success in orthotopic bladder reconstruction requires a collaborative approach involving the patient, urological surgeon, and a multidisciplinary healthcare team to ensure proper preoperative evaluation, surgical expertise, and ongoing postoperative care.

In summary, orthotopic bladder reconstruction offers a promising option for individuals undergoing radical cystectomy, providing a functional and anatomical substitute for the original bladder. While the procedure comes with potential advantages, careful patient selection, postoperative care, and long-term monitoring are essential for optimal outcomes.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKEY