We present our ten years experience of orthotopic substitution of the bladder affected by infiltrating urothelial carcinoma in order to estimate a relatively small number of patients but with a long follow-up and to outline the reasons for our technical choices. Since January 1986 we have performed 70 orthotopic substitutions of the bladder, using the Carney I at the beginning and then passing on to the Carney II “detubularized” neobladder and in the following years the ileo-cecal bladder, the VIP till the “J” neobladder now preferred by the authors. Technically we have identified a series of parameters that we have used to evaluate the different types of neobladder. This examination shows that all the neobladders utilized are valid, but the “J” type corresponds much better to the current concept of ideal neobladder. We have illustrated and explained critically the patient selection principles and the results we obtained.

Surgical therapy of serious cystocele must aim at restoring the area of support of the aponeurotic-muscular sheet of the pelvic floor and, if necessary, the supporting ligaments (round, utero-sacral). However it is not always easy to carry out this therapy, especially in the case of patients who have already been operated on using more or less complicated procedures. In such cases it is important to “limit the damage” i.e. to resolve the symptomatology without perfect anatomical correction, rather than undertake complex procedures which might be destined to fail or result in painful, dysuric symptomatology. With this aim in mind a simple operation is proposed which, on its own or combined with a hysterectomy with stabilizing of the vaginal cupola, depending on the case, has always obtained the desired results. The technique is that of putting a polypropylene mesh between the vagina and bladder.

We analysed the more common surgical complications we have noticed during our ten years experience of orthotopic bladder substitution. The critical review assesses these complications in relation to the different types of bladder substitution we used, beginning from Carney I up to the so-called “J” neobladder, following the natural development of our surgical technique from 1986 to the present (Carney II, ileo-cecal bladder, VIP). We described the early and late complications, carefully pointing out those known to be the most dangerous: enteric fistula, urinary fistula and ureteral reflux. We also reported the corrective treatments adopted and the preventive protocols we could eventually adopt in order to show if there are any technical methods that can significantly reduce the incidence of the above-mentioned complications.

In order to correct stress incontinence and/or cystocele we propose the well-known Burch technique modified by utilizing polypropylene strips (about 5 cm in length and 2 cm in width) for the suspension of the vagina to Cooper's ligaments, and, depending on the degree of cystocele and/or the severity of the uterine pathology, possibly associated hysterectomy and stabilization of the vaginal cupula to the uterosacral and round ligaments (always using the above-mentioned polypropylene strips). The aim of this technique is to avoid the complication considered by many authors to be the most frequent cause of failure in the surgery of stress incontinence and cystocele: tension of the suspension structures and threads. These strips may be used through either laparoscopic or laparotomic approach. The results we obtained could be described as satisfying; complications were rare.

Urinary stress incontinence is often related to cystocele, hence treatment cannot exclude correction of the latter. The authors have treated 2nd-3rd grade cystocele secondary to central impairment using a mininvasive technique consisting of a vaginal flap suspended anteriorly to the pubic tubercles, according to the traditional “Vesica kit” procedure, and posteriorly to the iliopubic branches in line with the Cooper ligaments using “Vesica kit” screws inserted through the abdominal wall under videolaparoscopy after creating a pneumo-Retzius space. Whenever a pneumo-Retzius cannot be created due to previous pelvic surgery, the same operation may be performed either through a small sovrapubic incision or by inserting 4 screws in line with the pubis. After 1 year the 20 operated patients show satisfying results with good prospects, but a longer follow-up is necessary to confirm these results. The aim of this study is to describe a mininvasive surgical technique for treating 2nd-3rd grade cystocele, associated or not with urinary stress incontinence.