Comparison of Orthotopic Sigmoid and Ileal Neobladders: Continence and Urodynamic Parameters

doi:10.1016/j.eururo.2004.10.018

European Urology

Volume 47, Issue 5, May 2005, Pages 679-685

https://doi.org/10.1016/j.eururo.2004.10.018 Get rights and content

Abstract

Objectives:

The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments.

Methods:

Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups.

Results:

The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7–32) ml/s, IN group 25.5 (range 5–35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night.

Conclusion:

A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

Introduction

Many different methods of bladder substitution have been developed in the attempt to achieve the goal of a neobladder that functions as well as a normal bladder. The ideal neobladder substitute should have adequate capacity, store urine at low pressure, preserve continence, evacuate via the urethra with minimal residual urine, preserve the upper urinary tract and renal function, and cause no or minimal metabolic disturbance. Various segments of small and large bowel have been used for neobladder construction.

The use of sigmoid colon for the creation of a continent voiding pouch was initially popularized in the United States at the University of Minnesota. The Minnesota group developed a partially detubularized U-shaped segment that later evolved into a fully detubularized sigmoid neobladder. Satisfactory results with this technique were described by the Minnesota group and others [1], [2].

Kock was the first (1969) to construct a continent low pressure ileal reservoir. The first (1979) who anastomosed ileum to the urethra were Camey and Le Duc [3], [4]. These techniques were modified and incorporated by Hautmann (1986) and many others [5], [6], [7]. Good functional outcome of this technique was reported by the Hautmann group [8], [9].

Whether an ileum or sigmoid configuration is used depends on the availability of bowel segments, the physical and physiological characteristics of bowel when it is incorporated in the urinary tract, and the preference of the surgeon. We report the long-term continence rates and compare urodynamic results of an ileal [9] and a sigmoid orthotopic neobladder constructed with a short distal segment of sigmoid [10].

Section snippets

Patient selection

From 1988 to 2000, 112 male patients underwent radical cystoprostatectomy for bladder carcinoma and construction of an orthotopic continent urinary reservoir at our institutes. Criteria for a bladder substitution were: absence of bladder neck invasion or prostatic infiltration, patients’ compliance, normal renal function and a good previous continence status. Relative contraindications were the presence of a diffuse carcinoma in situ (Cis) and lymph node metastases. Fifty patients received a

Free uroflowmetry

All but one patient could void spontaneously and performed free uroflowmetry. The results of free uroflowmetry are shown in Table 1. The patient who could not void required clean intermittent catheterization (CIC) 4 times a day to empty his (ileal) neobladder. At the moment of the assessment a PVR higher than 100 ml (but less than 250 ml) was objectivated in 8 (24%) of the patients with a SN and in 2 (10%) of the patients with an IN. The PVR in all but one of these patients remained stable or

Patient selection

The two groups of patients are only comparable with regard to the indication to perform a cystectomy and create an intestinal neobladder, due to bladder cancer. For example, mean age, period of follow-up and anti-reflux technique are different. Therefore, the authors caution the reader for an imbalance between the studied groups.

The difference in percentage of patients studied (32% of IN patients and 68% of SN patients) has several explanations. Cultural differences concerning either patients

Conclusions

A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate (90% versus 85%). The nighttime continence rate of SN is low (9%) due to a limited functional bladder capacity. Nighttime incontinence in patients with IN (40%) can at least partly be explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. While ileal neobladder meets the functional day and night

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