Orthotopic neobladder in women is a surgical procedure used as a form of urinary diversion, typically after the removal of the bladder due to conditions like bladder cancer. In this procedure, a new bladder, or neobladder, is created from a segment of the patient’s intestine. This complex surgery requires careful consideration of anatomical and functional outcomes, as well as potential complications, to ensure successful long-term results.

What is ortothopic neobladder?

An orthotopic neobladder is a type of urinary diversion surgery in which a new bladder, or “neobladder,” is constructed from a segment of the patient’s intestine and placed in the same anatomical location as the original bladder (orthotopic). This procedure is often performed following cystectomy, the surgical removal of the bladder, typically due to bladder cancer.

Indications of ortothopic neobladder in women

Here are the main indications for considering an orthotopic neobladder in women:

• Bladder Cancer: Women undergoing radical cystectomy for invasive bladder cancer are the primary candidates. The neobladder offers a more natural form of urinary diversion compared to alternatives like ileal conduit or continent cutaneous reservoirs.
• Benign Conditions: Although less common, some non-cancerous conditions that necessitate bladder removal, such as severe interstitial cystitis, neurogenic bladder, or refractory bladder dysfunction, may also be indications for neobladder reconstruction.
• Adequate Renal Function: Candidates must have good kidney function, as the new bladder is made from intestinal tissue that can absorb and secrete electrolytes, affecting metabolic balance.
• Intact Urethra: The urethra must be preserved and functional. The orthotopic neobladder relies on the ability to void through the urethra.
• Good General Health: The patient should be in generally good health to withstand a major surgical procedure and the subsequent recovery period.
• Patient Motivation and Capability: The patient must be motivated and capable of learning to manage the neobladder, which may include self-catheterization and monitoring for complications.
• Absence of Urethral Disease: There should be no significant urethral disease, such as urethral carcinoma or severe urethral stricture, which would contraindicate using the urethra for urine passage.
• Sufficient Bowel Length: Sufficient length of healthy intestine is necessary to construct the neobladder without significantly impairing bowel function.

Contraindications

Orthotopic neobladder reconstruction in women, while beneficial for many, is not suitable for all patients. Here are the main contraindications:

• Advanced Age: Older patients may have decreased physical resilience and an increased risk of complications from major surgery.
• Poor General Health: Patients with significant comorbidities (e.g., cardiovascular disease, severe pulmonary conditions) may not tolerate the surgical procedure well.
• Renal Insufficiency: Impaired kidney function can be exacerbated by the metabolic changes associated with a neobladder, increasing the risk of complications.
• Severe Bowel Disease: Conditions such as Crohn’s disease, significant radiation enteritis, or extensive previous bowel surgery can preclude the use of intestinal segments for neobladder construction.
• Involvement of the Urethra in Disease: If the urethra is affected by cancer or severe scarring, it cannot be used to pass urine, ruling out the possibility of an orthotopic neobladder.
• Extensive Pelvic Radiation: Previous extensive pelvic radiation can damage tissues and impair healing, making reconstruction more risky and less likely to succeed.
• Neurological Disorders: Conditions affecting bladder function, such as spinal cord injury or multiple sclerosis, can complicate neobladder management.
• Severe Incontinence: Significant preexisting urinary incontinence may worsen with a neobladder, leading to unsatisfactory outcomes.
• Psychological Factors: Patients with significant psychiatric conditions or cognitive impairments may struggle with the self-care required for neobladder management.
• Obesity: Severe obesity can increase the risk of surgical complications and negatively impact recovery and long-term outcomes.
• Patient Non-compliance: Patients who are unlikely to adhere to the necessary postoperative care and follow-up regimen are poor candidates for this type of surgery.

Complications

Here are some potential complications associated with orthotopic neobladder in women:

Immediate Complications

• Surgical Complications: Bleeding, infection, and injury to surrounding organs (e.g., intestines, blood vessels).
• Anastomotic Leak: Leakage at the junction where the neobladder is connected to the urethra or ureters.
• Thrombosis: Blood clots can form in the legs (deep vein thrombosis) or lungs (pulmonary embolism).

Short-Term Complications

• Urinary Tract Infections (UTIs): Increased risk due to the new anatomy and possible incomplete bladder emptying.
• Ileus: Temporary paralysis of the bowel, leading to nausea, vomiting, and abdominal distension.
• Urinary Leakage: Incontinence, especially during the initial recovery period.

Long-Term Complications

• Continence Issues: Persistent urinary incontinence, either stress or urge incontinence.
• Urinary Retention: Difficulty in fully emptying the neobladder, sometimes requiring intermittent self-catheterization.
• Metabolic Abnormalities: Electrolyte imbalances (e.g., metabolic acidosis) due to the absorption of urine components by the intestinal segment used to create the neobladder.
• Neobladder Dysfunction: Issues with the reservoir not functioning properly, leading to high pressure or inadequate capacity.
• Stone Formation: Development of stones in the neobladder due to chronic infection or incomplete emptying.
• Ureteral Stricture: Narrowing of the ureters where they are connected to the neobladder, leading to obstruction and possible kidney damage.
• Neobladder Prolapse: The neobladder can prolapse into the vagina due to weakened pelvic floor muscles.
• Sexual Dysfunction: Changes in sexual function due to nerve damage or anatomical changes.
• Cancer Recurrence: Risk of cancer recurrence in the neobladder or urethra, requiring ongoing surveillance.
• Psychological Impact: Adjustment difficulties, anxiety, or depression related to body image and changes in bodily function.

Monitoring and Management

• Regular Follow-ups: Essential for monitoring function, managing complications, and early detection of issues.
• Pelvic Floor Exercises: To strengthen muscles and improve continence.
• Education and Support: Training in self-catheterization, infection prevention, and metabolic management.

Advantages and effects on quality of life

Here are some of the key benefits and quality of life considerations:

Advantages                                                                                                                      

• Natural Urination: The primary advantage is the ability to urinate through the urethra, maintaining a more natural method of voiding compared to other forms of urinary diversion like an ileal conduit.
• Body Image: Because the neobladder does not require an external stoma or urostomy bag, it helps preserve body image and self-esteem.
• No External Appliances: Patients do not need to manage an external collection bag, reducing the daily maintenance and potential for skin irritation associated with urostomies.
• Improved Continence: Many patients achieve good daytime and nighttime continence, although this can vary and may require pelvic floor exercises and other management strategies.
• Lifestyle Maintenance: The neobladder allows for a more normal lifestyle, including the ability to participate in physical activities and maintain sexual function to a greater extent than some other urinary diversion methods.
• Psychological Benefits: The preservation of body image and the ability to urinate naturally can have positive psychological effects, reducing feelings of embarrassment or anxiety.

Quality of Life Considerations

• Adaptation Period: There is an initial adaptation period where patients learn to manage the neobladder, including establishing a voiding schedule and potentially performing intermittent self-catheterization if necessary.
• Continence: While many achieve good continence, some patients may experience stress incontinence or nocturnal enuresis (nighttime incontinence), which can impact quality of life. Pelvic floor muscle training can help improve continence.
• Sexual Function: Preservation of the urethra and vaginal anatomy can help maintain sexual function, though some women may experience changes in sensation or function that require adjustment or therapy.
• Monitoring and Follow-up: Regular follow-ups are necessary to monitor for complications such as infections, stone formation, and metabolic imbalances. This ongoing medical oversight is crucial for long-term health.
• Dietary and Lifestyle Adjustments: Patients may need to make dietary changes to manage metabolic changes, including ensuring adequate hydration to prevent stone formation and infections.
• Empowerment through Education: Comprehensive preoperative education and postoperative support can empower patients to manage their neobladder effectively, enhancing their confidence and independence.

Long-Term Satisfaction

• High Satisfaction Rates: Studies have shown that many patients report high levels of satisfaction with their quality of life after orthotopic neobladder surgery, appreciating the return to a more normal lifestyle.
• Social and Occupational Benefits: Being free from external appliances can improve social interactions and occupational activities, leading to better overall life satisfaction.

Summary

An orthotopic neobladder in women is a surgical procedure used to create a new bladder from a segment of the intestine, typically following bladder removal due to cancer. The neobladder is connected to the urethra, allowing for more natural urination. This procedure offers several advantages, including the preservation of body image, no need for external appliances, and the potential for good continence. However, it requires careful patient selection, as it is not suitable for those with poor health, renal insufficiency, or certain anatomical challenges. Complications can include infections, incontinence, and metabolic imbalances. Despite these risks, many women experience improved quality of life and high satisfaction post-surgery, benefiting from a return to a more normal lifestyle. Regular follow-ups and proper postoperative care are essential for successful outcomes.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE