Chemo Day 62 - All about neobladders

While on vacation, I’ve been doing some research regarding the Studer-type neobladder, which Dr. Schoenberg is recommending.  Warning:  The following likely will appeal only to future readers who are facing similar surgery (good luck!), family members who are starved for details (hi, Mom!), or others who have nothing better to do. 

Historical overview of urinary diversions and neobladders (with pictures!):  http://emedicine.medscape.com/article/451882-overview#showall

Detailed illustrations on each step of the surgery (pretty amazing stuff):  http://radipedia.com/WikiMedia/images/2/21/Surgical_Images_of_Ileal_conduit.pdf

BCAN’s newsletter, discussing the types of urinary diversions:

http://www.bcan.org/stay-informed/newsletter/november10/diversions/

BCAN interview re a neobladder recipient, explaining what is involved with getting a neobladder, and what to expect after surgery:

http://www.bcan.org/facing-bladder-cancer/frequently-asked-questions/treating-bladder-cancer/neobladder/

Here’s the text of the interview:

An orthotopic neobladder is an internal urinary diversion in which a segment of the small intestine is used to form a new (neo) reservoir for urine. The ureters are attached to the neobladder, as is the urethra, allowing voiding to be done via the natural course.

How is neobladder surgery different from other types of urinary diversion?
Michael: The most important issue is your medical suitability for a neobladder. Neobladder surgery is a lengthy procedure (about twice as long as construction of an ileal conduit, the simplest and most often used diversion) and you will need to be in good general health to undergo this surgery.

You must, before surgery, discuss with your surgeon what he/she will do if, during surgery, it becomes clear that you are not physically able to have a neobladder and another type of urinary diversion needs to be made instead. I believe this situation is most often caused by finding cancer or CIS in or near the urethra during the RC surgery.

After the construction of the neobladder were you able to use the system right away?
Michael: There seems to be a variation in practice among urologic surgeons. In my case I had only a Foley catheter when I was discharged from the hospital. This remained in for about 3 weeks after I went home to allow complete healing of the anastamoses (junctions between the urethra and neobladder, and the ureters and neobladder). During this time the catheter, at least in my case, was prone to getting plugged with mucus so I needed to irrigate it with sterile saline frequently. Discharge instructions were to irrigate at least three times per day until no mucus was noted in the withdrawn fluid. After the catheter was removed there was a period of training the sphincter muscle and stretching the neobladder to maximum capacity. During this time a “Depends” type of undergarment and, later, just a pad were needed. Some surgeons also use a supra-pubic catheter to relieve pressure in the neobladder in the immediate recovery period.

How often do you void with a neobladder?
Michael: Time to void depends on a number of variables including the amount of fluid intake and the amount of fluid lost through, say, perspiration rather than urine. In the early stages of recovery the time will be quite limited due to leaking. Early on the neobladder is a low volume, high pressure reservoir and the pressure easily overwhelms the capacity of the sphincter muscles to retain urine. With time the neobladder stretches to become a low pressure, higher volume reservoir and the sphincter, under most conditions, then retains the urine. The stretching is accomplished by gradually increasing the time between voiding. For me the time between urination can be as little as 1-2 hours under conditions of high intake, especially of fluids such as coffee, tea or alcohol that have a diuretic effect (IE: increase urine production). However, I sometimes go greater than 4 hours if intake is less and therefore urine production is slower (such as periods of exercise where sweating and water loss through respiration may exceed that taken in.) The length of time to achieve continence seems to be quite variable with some people achieving daytime continence within a few weeks and others taking a few months. I believe daytime continence is achieved in about 95% or more people with neobladders. Certain medicines with a diuretic effect may also play a role in voiding frequency. Because I do not take any such medications I do not have any direct knowledge of this as a factor.

How much does the neobladder hold?
Michael: My understanding is that ideally the neobladder should hold approximately 500-600 cc. It can be stretched to hold more, but this increases the risk of becoming unable to empty it completely. Incomplete emptying with residual urine in the neobladder is one cause of urinary tract infections, so it is best to limit the capacity of the neobladder. For most men complete voiding is best when seated and with alterations in upper body position (leaning forward). I also apply pressure to the lower abdomen with my hands in the area that overlies the neobladder to increase the pressure on the neobladder to empty completely. I am very obsessive about this and will usually repeat these maneuvers until no more urine is expelled.

How do you sleep?
Michael: At night I wake every 3-4 hours to void. I void immediately before bed and attempt to empty the neobladder completely. I set an alarm clock for between 3 and 4 hours to insure that I do not over-stretch the neobladder. If I naturally wake after about 2 or more hours before the alarm goes off, I void and reset the alarm. For me this usually amounts to getting up twice during the night. There is more of a problem of continence during sleep as the sphincter, a voluntary muscle, is less controlled in a deep sleep. There is a greater chance for nighttime incontinence than for daytime incontinence, but a large percentage of people do achieve both day and night continence. For most, an absorbent pad would suffice for incontinence problems.

What daily maintenance do you need?
Michael: In my case, none. I do stay well hydrated (I almost never go a day without having at least 80 oz of fluid intake, primarily water and iced tea). One complication of continent diversions (neobladders and internal continent reservoirs such as the Indiana pouch) is metabolic acidosis. This is a potential problem due to the natural movement of water and electrolytes between the inside of the reservoir and the surrounding tissues and blood stream. Good hydration lessens the risk of acidosis as well as lowering the risk of stones. I also try to be quite vigilant through frequent urination about not over-distending the neobladder. Some people with neobladders have a continuing need to self catheterize, usually because of hyper-continence. This risk is minimized by preventing over-distention.

What is the risk of infection?
Michael: Urinary tract infections are more common in all urinary diversions (neobladders, Indiana pouches, and ileal conduits); I believe the risk is similar for each of the urinary diversions. To date, approximately 20 months since my surgery, I have had none. The risk is higher in those with diabetes mellitus. The usual symptoms – urgency, frequency, and burning when urinating – are absent in urinary diversions, so we must try to be aware of other symptoms, such as a strong or different odor (that can’t be explained by dietary factors such as asparagus), chills and fever. Pain in your side with chills and/or fever may indicate a kidney infection which is a serious medical complication requiring immediate treatment, often with IV antibiotics. Routine urinalysis is not of much help since most diversions will harbor white blood cells and result in positive tests. A urine culture with sensitivity is needed to determine an infection and appropriate treatment.

Are there any restrictions in lifestyle?
Michael: None. The external appearance is normal except for the scar from the surgery. My surgeon has placed no restrictions on my activity and I currently live an active lifestyle with travel, bicycling (approximately 60-100 miles per week), and weight training. You may swim or engage in other physical activities. As with all diversions there is an adjustment period to your new normal.

How satisfied are you with a neobladder?
Michael: I am very satisfied, but firmly believe that we are very adaptable and will accommodate to any diversion with time.

What to expect after RC surgery: See the discussion at http://www.inspire.com/groups/bladder-cancer-advocacy-network/discussion/having-surgery-typical-issues-to-look-for-after-your-r-c/ 

Random Thoughts and Tips on Urinary Diversions, excerpted from; A Guide to Bladder Cancer, Urostomy and Impotence, by Roni Olsen, posted at http://www.inspire.com/groups/bladder-cancer-advocacy-network/discussion/neo-bladder-4/

Here’s the text:

It is not essential to have a urinary bladder to sustain life, but it is essential to maintain an uninterrupted flow of urine from the body. Fortunately, this can be accomplished with one of the urinary diversion procedures. The urostomy resulting from this surgery is not the end of life but rather a means of prolonging life, a second chance at life for those whose urinary bladders must be removed. Understanding the critical role of ostomy surgery, however, is essential to both the physical and psychological adjustment to the altered body function and diminished self esteem that routinely accompany most ostomy surgeries. As body strength is regained following radical cystectomy, the physical and mechanical problems of dealing with any ostomy moderate and even become routine, but the psychological adjustment often takes a much longer period of time. Each urostomy patient will, of course, have his/her own set of physical and psychological problems with which to contend. Some will have the support of a caring family and/or friends to help them through the period of adjustment, and others less fortunate may have to fight the uphill battle alone. Whatever the circumstance, each urostomate's attitude is ultimately the key to life with a urinary diversion. Although a urinary diversion definitely alters body function and requires some relatively minor daily maintenance, it need not permanently limit a person's activities, abilities, interests or horizons. The urostomate in tune with life will understand that each day is a very special gift to be treasured and not wasted, exhilarate in the love and laughter of children, family and friends, embrace the climb to the mountain top, rejoice in a journey through minarets at sunset, welcome the new beginning of each spring, and pause to smell the roses along the way.

The three most common types of ostomies are: colostomies, ileostomies and urostomies. Urostomies (urinary diversions) are probably the most complicated because they connect directly to a life-supporting system, the kidneys. Additionally, due to the relatively rare demand for radical cystectomy, many urological surgeons have very little experience with creating a urinary diversion and/or and stoma construction. To help minimize problems, the candidate for ostomy surgery should be advised to select a surgeon who is experienced in the particular type of surgery he/she needs. Many factors bear on operating time, procedure options and complications, such as:
The patient's health, weight and age
The condition requiring cystectomy and/or extent of disease
The effect of radiation and/or chemotherapy, and
The experience and dexterity of the surgeon

There are three main types of urinary diversions:
Incontinent
Internal continent reservoirs (pouches) with an abdominal stoma
Internal continent reservoirs that are reconnected to the urethra to provide normal urination.
The incontinent urinary diversion, also known as the Bricker's loop, ileal loop, or ileal conduit, was developed in the 1950s and rapidly became the gold standard for urinary diversion. It is still the most frequently performed urinary diversion, primarily because it is a relatively uncomplicated procedure, and it is also the only urinary diversion procedure most urologists have been trained to perform. Although the majority work reasonably well, the ileal conduit is far from the perfect solution because of the higher incidence of ureter and stoma strictures and urinary reflux to the kidneys. These strictures frequently impair, or even block, urine flow, and may require surgical revision. Additionally, the incidence of ascending bacteria and urinary reflux remains substantial and results in repeat kidney infections and progressive kidney deterioration in up to 30% of the cases.

The ileal conduit is made from a 6 to 10 inch long segment of ileum (small intestine) which is separated from the small intestine with its blood and nerve supply, the web-like mysentery, carefully preserved. One end of the conduit is closed with stitches or staples, and the other end is brought to the surface of the abdomen to form a stoma (opening). The ureters are implanted into the closed end of the conduit which serves as a pipeline for a steady flow of urine from the ureters through the abdominal stoma and into an external appliance (bag) attached to the abdomen. Ideally, urine should flow continuously through the stoma at approximately twelve to fifteen drops per minute. A healthy stoma is pink to red in color and also excretes mucus and moisture, both normal excretions of the ileum. Fortunately, the long stringy mucus threads flow easily with urine.

It is not uncommon for people with ileal conduits to have leakage around the appliance faceplate and/or a variety of peristomal skin (skin around the stoma) problems. Urostomates need to be aware that stoma size and shape may change, especially with weight gain or loss or an increase in physical activity, that leaking may occur, and a different type of faceplate and appliance may be required. Although this is particularly common during the first few months after surgery, it can happen at any time. Fortunately, a variety of urinary appliances is available, ranging from a one-piece disposable with a soft, flexible faceplate to a two piece reusable appliance with a semi-rigid or rigid plastic faceplate. If the stoma is flush with the abdomen or located in a body fold, it may be necessary to use an appliance with a semi-rigid convex faceplate and a belt to help make the stoma protrude in order to prevent leakage. Care must be taken to routinely check the appliance fit and make any necessary adjustments. The faceplate opening should fit within 1/8 to 1/16 of an inch around the stoma.

Common peristomal skin problems include yeast and fungus infections, pimples, ulcerations, warty looking, gray, raised encrustations and/or white crystal deposits on the peristomal skin and/or stoma. These conditions require prompt and appropriate treatment by an ET Nurse (also called Ostomy/wound nurses). Since all ET Nurses do not have equal urostomy experience, however, it may be necessary to seek out another ET if problems persist. Prescription medications may be required for severe skin conditions. Preparations that contain cortisone must be used sparingly because they have the potential to cause skin to become thin and fragile with prolonged use. Urostomates should check with an ET Nurse or physician for specific directions before using any skin products.

The two most common causes of skin irritation are chemical and mechanical that are caused by leaky urine and rough treatment of the skin. Chemical irritation results from the exposure of peristomal skin to urine, adhesives, solvents, cleansers, and soap. Since allergic skin reactions are always a possibility, new products should always be tried out on a small area of skin outside of the faceplate. Peristomal skin and stomas that are awash in urine are prime targets for leaks, skin irritations, and crystal buildup around the stoma, especially during the postoperative period when the greatest change in stoma size and shape occurs.

Mechanical irritations are usually caused by improper appliance removal and/or close shaving, which may strip protective layers off of the peristomal skin. To minimize damage, the faceplate should be removed gently by carefully pushing the skin away from the adhesive, instead of pulling the adhesive away from the skin. Also, starting at the top of the faceplate and slowly working toward the bottom reduces tearing and pulling on the skin as well as the hair follicles, which grow in the same downward direction. Vigorous scrubbing or use of abrasive cleansers also damages the skin. Adhesive removers may be used sparingly and gently if necessary. Body hair on the peristomal skin occasionally needs to be carefully shaved or clipped with scissors to further reduce pulling of the hair and skin. An electric razor can be used, but disposable razors are not recommended because they may damage the top layer of skin. Occasionally, it is necessary to air the peristomal skin. It helps to find a warm, private, comfortable place to sit and read or watch TV, and to place a waterproof pad or a towel underneath. The continually flowing urine can be absorbed with several wicks (made from a paper towel, rolled up like a cigarette and taped in the middle), a cotton filled small mouth bottle that fits around the stoma or a clean folded washcloth carefully positioned under the stoma. A hair dryer set on cool, held at least one foot away from the stoma, will speed drying time. Any urine that gets onto the skin during the airing process should be gently washed off with a clean warm cloth.

Since it is imperative to insure a constant flow of urine away from the stoma, the appliance needs to be connected to a long thin tube that drains into a collection jug at night or when lying down for a few hours. The tube and jug need to be cleaned daily with one of the germicidal solutions. The reusable appliances also need to be cleaned in a similar manner when changed, typically every three to six days.

In the early 1970s, Dr. Nils Kock introduced his innovative Kock continent ileostomy pouch, an internal reservoir for ileostomates who required colon removal. This also opened the door for the development of continent urinary reservoirs. The Kock pouch (Kock continent urinary pouch - pronounced "coke") is made from approximately two feet of ileum. At each end of the pouch an intussuscepted valve (folded back on itself like a turtleneck to prevent leakage and/or reflux) is created. The ureters are connected to the internal valve which prevents reflux to the kidneys, and the end of the other valve is brought to the abdominal surface to form a small continent stoma (does not require an external appliance, just a small pad).

The Kock pouch is emptied by inserting a soft silicone catheter with a coude tip (firm tip) into the stoma 4 to 8 times a day. Catheterization is convenient, easy and painless, and maintenance is minimal. The Indiana pouch and several other varieties, including the Mainz, Miami, Studer, and Mitrofanoff, are also internal continent reservoirs that are catheterized. They are much simpler to construct than the Kock pouch, use the cecal valve as the continence mechanism, and they also hold a smaller volume of urine. All of these continent pouches have a moist stoma that needs to be covered by a small waterproof pad to protect clothing. A third of a Maxi-Thin pad, held in place with two small pieces of micropore tape, works quite well as a stoma cover. Although catheterization is not a sterile procedure, the catheters should be rinsed and cleaned with a germicidal solution after each use. Again, it is wise to check with an ET Nurse for directions. Catheters fit easily into a small plastic ziploc bag, as well as a pocket, purse, backpack, or glove compartment and should always be available.

For men and women who meet special criteria, the T-pouch (similar to the Kock pouch), and the neobladder (Studer and variations) can be reconnected to the urethra to provide normal urination. These reconnects require a lot of patience and retraining of muscles to control urine flow, and some individuals never achieve 100% continence. The majority find continence is easily maintained during the daytime, but may need to wear a pad as a safety measure. Nighttime incontinence, however, remains a problem for many. Some people wear Depends, some get up a few times during the night, and some men use a penile sheath with a tube connected to a collection jug. Some individuals end up with hypercontinence which means they have to catheterize themselves through the urethra to empty the neobladder.

In most cases, radical cystectomy renders the male impotent, an understandably frightening and psychologically intimidating prospect for even the most stoic individual to contemplate. In appropriate cases, however, a nerve-sparing technique can be used to maintain erectile function. Once again, the skill and experience of the surgeon is critical. Over the past two decades, medicine and engineering have combined to develop a variety of penile prostheses which provide acceptable alternatives to impotence. The three-piece inflatable prostheses are the most comfortable, unobtrusive and satisfactory. As a result, sexual rehabilitation for men is an integral part of treatment for radical cystectomy, an important step that plays a major role in restoring both self-image and an acceptable quality of life to the male urostomate. Although none of the prostheses provide an exact duplication of a natural erection, the penile implants are sufficiently similar to allow the patient to resume sexual activity close to what he enjoyed prior to the surgery. Also, since 1982, the use of vasodilatory drugs, PEP and Caverjet, the pharmacological erection program, or penile injection has produced satisfactory results for a large number of men and their partners.

Medical Journals:

Postoperative management and results in patients with an orthotopic ileal neobladder

Full text at  http://www.actasurologicas.info/v32/n03/ENG/3203OR04.htm

KWB Note: This entire article is well worth reading

 Álvarez Ardura M, Llorente Abarca C,  Studer UE*.

Department of Urology. Fundación Hospital Alcorcón. Madrid. *Department of Urology. University of Bern Inselspital. Bern Switzerland

Actas Urol Esp. 2008; 32(3):297-306

ABSTRACT

Urinary tract reconstruction after radical cystectomy has evolved from simple urinary diversion to functional and anatomic restoration as close as possible to the patient’s preoperative state. Over the past 20 years, orthotopic reconstruction has evolved from experimental surgery to the preferred method of urinary diversion in both sexes. Urologists performing this technique should have experience in pelvic surgery and be able to perform nerve sparing radical cystectomy. Nevertheless, postoperative management of these patients is the most important factor, for which an extensive knowledge of neobladder physiology, postoperative complications and their treatment is required. We review the most important aspects in the postoperative management of patients with ileal neobladder. We also review long-term results regarding continence, sexual function, renal impairment, oncologic safety and quality of life.

Long-term functional outcome and late complications of Studer's ileal neobladder

http://www.ncbi.nlm.nih.gov/pubmed/15976064

Jpn J Clin Oncol. 2005 Jul;35(7):391-4. Epub 2005 Jun 23.

Tanaka T, Kitamura H, Takahashi A, Masumori N, Itoh N, Tsukamoto T.

Source: Department of Urology, School of Medicine, Sapporo Medical University, N-1, W-16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan. zappa@pop12.odn.ne.jp

Abstract

OBJECTIVE: The purpose of this study was to evaluate the long-term functional outcome and late complications of Studer's ileal neobladder.

METHODS:  The study included 57 patients who underwent radical cystectomy and bladder reconstruction with Studer's ileal neobladder, and were followed-up for at least 3 months after surgery. The voiding and storage function, and late complications were evaluated. The times of evaluation after surgery were categorized into periods I (3-23 months), II (24-59 months), III (60-95 months) and IV (> or =96 months).

RESULTS:  Daytime and night-time continence rates were 95.6 and 88.6%, respectively. The averages of functional capacity (439 ml), maximum flow rate (15.7 ml/s) and residual urine (35 ml) evaluated in period I were maintained in period IV. Of the 57 patients, intermittent self-catheterization was needed in five (8.8%) due to incomplete emptying or urinary retention. Urethroileal anastomotic stricture was found in two patients (3.5%), who were successfully treated by transurethral intervention. Inguinal hernia was found in seven patients (12.8%), five of whom developed it within 2 years after surgery.

CONCLUSIONS: Our results indicate that Studer's ileal neobladder had a favorable long-term functional outcome. Although late complication rates were low, the incidence of inguinal hernia was relatively high, and this was considered as a definite late complication in our study.

Studer's type ileal neobladder. Study of complications and continence [Article in Spanish]

http://www.ncbi.nlm.nih.gov/pubmed/9949571

Actas Urol Esp. 1998 Nov-Dec;22(10):828-34.

Gutiérrez Baños JL, Martín García B, Hernández Rodríguez R, Portillo Martín JA, Correas Gómez MA, Del Valle Schaan JI, Roca Edreira A, Villanueva Peña A, García Gutiérrez R, De Diego Rodríguez E.

Source: Servicio de Urología, Hospital Universitario Valdecilla, Santander, Cantabria.; Erratum in Actas Urol Esp 1999 Jan;23(1):82.

Abstract: Analysis of early and late post-surgical complications in 44 cases of Studer's type bladder replacement due to carcinoma of the bladder performed over a 6-year period. Follow-up ranges between 6 months and 6 years. 4 patients died during the post-operative (9.09%): 1 myocardial infarction, 1 pulmonary embolism and 2 intestinal fistula. 28 patients (63.64%) had post-operative complications: 4 GI fistula (9.09%) 5 ileus (11.36%), 2 GI bleeding (4.54%), 1 ureteral fistula (2.27%), 1 ureteral stenosis, 6 urethro-intestinal fistula (13.36%), 1 tubular necrosis, 1 ruptured ureteral catheter, 5 wound infections (11.36%), 12 urine infections (27.27%), 6 sepsis (13.63%), 1 lymphocele, 1 evisceration and 2 eventrations. Repeat surgery was required in 6 cases. Within 6 months from discharge, 7 of 40 patients (17.5%) had some complication: 3 acute pyelonephritis, 4 episodes of acidosis-dehydration and 1 ureter stenosis. After 6 months, 7 of 38 patients (18.4%) had complications: 1 acidosis, 3 vesical lithiasis, 2 ureteral stenosis and 1 urethro-intestinal, plus 2 cases of chronic urinary retention. Daytime continence was 97.2% and nighttime continence 30%; after 6 months evolution, no further changes were seen.

Management of bladder cancer with Studer orthotopic neobladder: 13-year experience

http://circiruj.edilaser.net/en/pdf/7706/2009-77-06-411-417.pdf

Andrés Martínez-Cornelio,* Narciso Hernández-Toriz,* Joel Quintero-Becerra,*

Donaciano Flores-López,* Jorge Moreno-Palacios,** and Emanuel Vázquez-Martínez**

Introduction

Urinary diversion through ileal conduit has been regarded as the standard procedure after radical cystectomy from bladder cancer.  However, in the last 20 years other aspects have gained interest, mainly regarding patient’s body image and quality of life through the use of substitute orthotopic bladders.1  The first orthotopic bladder reconstruction in humans was described by Lemoine in 1913.2 In 1979, Camey and Le Duc reported their experience with neobladder creation from small intestine while preserving the urethral sphincter during cystectomy.3  In 1985, Studer et al. published their first experience with low-pressure orthotopic neobladder (ONB) replacement in animals.4

Abstract

Background: We present the results of patients submitted to a Studer type urinary orthotopic derivation after radical cystectomy. 

Methods:  The files of patients with bladder cancer submitted to a radical cystectomy plus the procedure of the ileal neobladder were reviewed in our hospital from January 1992 until December 2004.  Patients were divided into two groups:  Group A—60 years old and younger, and Group B, greater than 60 years old. 

Results: From 306 patients submitted to radical cystectomy with urinary derivation, there were 42 patients (13.7%) included with Studer type neobladder. There were 34 (80.9 %) men and 8 (19.1%) women, with an average age of 60 years. Average surgical time was 7 h with an average blood loss of 1600 cc requiring transfer to intensive care unit (ICU) in 55% of the cases. The most frequent early complication was metabolic acidosis that was present in 28 (66%) patients. The most severe complication was ileal-ureter urinary leak, which was present in seven (16.6 %) patients. Among the most frequent late complications are the day- and night-time urinary incontinence often related to urinary infections and intestinal occlusion. Overall 5-year survival was 71%, cancer-specific mortality was 15% and surgical-related mortality was 7.3%.

Conclusions: The performance of procedures with orthotopic neobladders is actually feasible in experienced hospital centers and is a valuable alternative to urinary heterotopic derivation with ileal conduit. Postoperative patient management and regular follow-up is of major importance.

Continent Urinary Diversion/Neobladder, from Urologic Surgeons of Washington, http://www.dcurology.net/bladder/cudn.html

After the bladder has been removed, the surgeon needs to create a new "bladder" for the urine to pass from the patient's body. This is called a urinary diversion. There are many options that have been developed for urinary diversion after the radical cystectomy, and some of them are listed below. Preoperatively, all patients who are having a radical cystectomy are required to undergo a full bowel preparation, to clear the bowel of any contents, in preparation for creation of the urinary diversion. The bowel is then used to build the new "bladder" or urinary conduit.
The most common urinary diversions utilized today (and are performed by the surgeons in our group) include the following:

1. An ileal conduit - this surgical technique uses a segment of the small bowel, to serve as a channel for the urine to flow from the ureters out to a new opening on your abdomen, called a stoma. Once the urine passes through the stoma, it collects in a plastic stoma bag attached to the skin. The bag needs to be emptied several times a day.
2. A continent reservoir - there are many types of reservoirs that have been used over the years by Urologists. We use an Ileocecal reservoir (Indiana Pouch). This technique uses a portion of the large bowel, and a portion of the small bowel. The large bowel serves as the new storage container (bladder). The ureters are attached to the large bowel. The urine is stored for several hours in this bowel segment, and then drained through the small bowel portion, which has a very small opening in the abdominal skin (stoma). Periodically the patient has to pass a urinary catheter through the skin stoma, into the small bowel and finally into the large bowel. The urine is drained through the catheter into the toilet. The advantage to this approach is that most patients are dry between catheterizations, and do not need a urinary storage bag (stoma bag) to be worn on the outside of the body.
3. A "neobladder" - this is a more highly specialized form of a continent reservoir (see above). There are several versions of this technique. We use the Studer neobladder, which requires approximately 60 cm of small bowel. The small bowel is reconfigured, the ureters are attached to the upper end of the new bladder, and the end down in the pelvis is attached to the remaining urethra. This allows the patient to pass the urine normally through their urethra. Sometimes people need to use a urinary catheter to drain the urine.

In preparation for the surgery, all patients require a formal bowel preparation to include a mechanical cleansing, and antibiotics. The cleansing of the bowels is absolutely required since the bowel will be used to create the urinary diversion or the "new" bladder. All patients will also have to give a blood specimen for type and screen.
For your upcoming surgery, you will be given a form with the date and time of surgery, and the time you should arrive at the George Washington University Hospital. Many patients park at a Metro stop and take the Metro train to Foggy Bottom/GWU, which is located in from of the hospital lobby. Alternatively, there is a parking garage on I Street, less than 1 block from the hospital.
On the day of surgery your surgeon will greet you in the pre-op area and answer any last minute questions that you may have. You will meet the anesthesia team, and several peri-operative nurses. You will also meet our resident house staff. These doctors will be involved in your hospital care, and you will most likely see them several times after your surgery has finished. It is a busy time, but your family will be able to stay with you for most of the preoperative time, until you are taken back to the operating room.
As with any major operation, there are risks associated with the performance of a radical cystectomy and urinary diversion. The risks of these operations include but are not limited to bleeding, infection, damage to the lung, pleura, liver, spleen, bowel, nerves, major vasculature, and major complications related to prolonged surgery and anesthesia (blood clots, heart attack, pneumonia, stroke and death).
Postoperatively, most patients are taken to the intensive care unit (ICU) for close monitoring. If things go well, transfer to the the main surgical ward occurs in the first couple of days. However, ICU care may be necessary for several days. Patients are typically in the hospital for 7 to 10 days after this particular operation. During this time you will meet with the enterostomal nurse who will work with you and your spouse, or significant other. She will help educate you on the proper care of your "new" urinary tract.
Upon discharge from the hospital, you will be given a prescription for pain pills and stool softeners. You may need to use the pain medication for several days, but we encourage you to quickly transition to Tylenol for pain control, and use the narcotic pain medication sparingly. While at home, if you experience a dramatic turn for the worse, such as increasing belly pain, nausea and vomiting, fevers (> 101 F) and chills, shortness of breath, chest pain, or unilateral leg swelling, you should return to the hospital emergency room (ER) right away for re-evaluation.
After surgery, you will also need to actively care for your newly formed stoma, and / or reservoir.

1. Ileal conduit - the stoma bag will need to be changed every few days. During this time, the skin around the stoma and the stoma will need to be cleaned. The enterostomal nurse at GWUMC will meet with every patient to teach the proper care of the newly formed stoma.
2. Continent reservoirs. These urinary diversions are more complex and require a larger commitment from the patient to maintain.
1. Indiana pouch - post operatively the patient will notice a large tube coming through the skin from the reservoir (cecostomy tube), 2 smaller tubes coming through the skin (ureteral stents), a tube coming from the stoma (red Robinson), and a drain in the pelvis. The ureteral stents will stay in for 7-14 days. . The red Robinson will also be left in for 1-2 weeks. The pelvic drain is left in until the average daily output is minimal, and varies from patient to patient. The cecostomy is typically left in for 1 month. The cecostomy is used to irrigate the newly formed pouch on a daily basis, to clear any build up of mucous. The frequency of these irrigations will decrease with time, and should be discussed with the enterostomal nurse and urologist. Once the new reservoir is showing signs of proper healing, the ureteral stents are removed, and the red Robinson catheter is removed. The patient is then taught how to place a urinary catheter into the newly formed stoma to begin the process of draining the new bladder. Once the self-catheterization process through the stoma is successfully mastered, the cecostomy tube is removed.
2. Studer neobladder - post operatively the patient will notice a large tube coming through the urethra (urethral foley), 2 smaller tubes coming through the skin (ureteral stents), a larger tube coming through the skin (suprapubic (SP) tube), and a pelvic drain. The ureteral stents will stay in for 7-14 days. The urethral foley will be left in for 2-3 weeks. The drain is removed when the drainage is minimal. The SP tube is typically left in for 1 month. The SP tube is used to irrigate the newly formed pouch on a daily basis, to clear any build up of mucous. The frequency of these irrigations will decrease with time, and should be discussed with the enterostomal nurse and urologist. Once the neobladder is showing signs of proper healing, the ureteral stents are removed, and the urethral foley catheter is removed. The patient is then taught how to clamp the SP tube, and void through the urethra. Early on, the patient may have some trouble voiding naturally, so the SP tube is left in place to serve as a temporary drainage port. Once the patient has successfully mastered the art of draining the bladder through the urethra (by valsalva, or urethral catheter), the SP tube is removed. Over time, the patient is taught how to irrigate the neobladder through the urethral foley catheter.

In follow up, the patient is monitored for recurrence of his cancer, through periodic examinations, radiographs, and lab tests. It is also important that various blood tests are checked to monitor the salt and acid/base balance in the body. Finally the patient needs to be aware that Vitamin B12 my become deficient over many years, and this too should be monitored.

Management of Urethral Recurrence in Patients with Studer Ileal Neobladder

http://www.europeanurology.com/article/S0302-2838%2803%2900096-4/pdf/Management+of+Urethral+Recurrence+in+Patients+with+Studer+Ileal+Neobladder

Jorge Huguet* , Juan Palou, Marc Serrallach, Francisco Javier Sole ´ Balcells,

Jose ´ Salvador, Humberto Villavicencio

Urology Department, Fundacio ´ Puigvert, Cartagena 340, 08025 Barcelona, Spain

Abstract

Objective: The overall risk of urethral recurrence (UR) of transitional cell carcinoma (TCC) in patients with orthotopic neobladder ranges from 2% to 6%. We are presenting herein our experience in order to evaluate and define the management of these patients, since the cases with urethral recurrence in patients with orthotopic neobladder are very scarce.

Materials and methods: Five hundred and sixteen radical cystectomies due to TCC were performed at our Centre between January 1990 and February 1998. One hundred and thirty-eight of them (26.7%) underwent an orthotopic neobladder procedure with the Studer’s technique. We are reviewing five cases of UR in patients with orthotopic neobladder, the cystectomy indications and the differences between the clinical and the pathologic stages. We are also assessing its clinical presentation, diagnosis, treatment and evolution.

Results: Five patients (3.6%) from 50 to 71 years old with Studer’s orthotopic neobladder presented with UR. All of those neobladders were initially superficial TCC, mostly multifocal, and all had failed the endovesical treatment.  Endoscopic treatment was administered in two cases with superficial UR. One patient with urethral CIS received intraurethral BCG instillations. One case because of multiplicity, and another due to the presence of an infiltrating urethral tumour, underwent urethrectomy and neobladder exeresis. In both cases, the intact 15–20 cm isoperistaltic proximal ileal limb of the Studer-type orthotopic neobladder was used as an ileal conduit.

Conclusions: UR in patients with orthotopic bladder substitution is unusual. A conservative approach is possible when dealing with superficial recurrences. In cases of urethrectomy, the isoperistaltic proximal ileal limb of the Studer neobladder may be used as an ileal conduit.