Orthotopic bladder substitution: Surgical aspects and optimization of outcomes

Abstract

Objectives Orthotopic bladder substitution (OBS) is a management option for urinary diversion in men and women undergoing cystectomy. The aim of the procedure is to provide a functional continent urinary reservoir of adequate capacity, compliance and low pressure. We have provided a narrative review of the existing literature and highlighted areas where improvement and standardization can be recommended. Methods Literature search included database search for publications from January 1970 to November 2020, using keywords including OBS, bladder reconstruction, neobladder, radical cystectomy, robotic cystectomy, intracorporeal neobladder, surgical technique, patient selection and outcomes. Results Due to various factors including indications, operative technique and risk of complications, OBS is an enormous undertaking and commitment for patients, surgeons and health professionals involved in the care pathway. The main considerations for patient selection, the technical elements of the procedure and the rationale behind these are discussed. Previously considered to be a choice for a select few, the inclusion criteria have expanded over the last decade. Similarly, surgical techniques including the choice and configuration of bowel segments, construction of anastomosis and nerve or organ sparing procedures have evolved over the years. Minimally invasive laparoscopic and robotic assisted surgery has added further perspectives to the existing literature on OBS. Understanding the principles of operative techniques and assessing the best evidence to influence patient management is crucial as it has a major impact on clinical outcomes. Peri‐ and post‐operative care, focused on the prevention of complications and morbidity, affects long‐term functional and oncological outcomes, which ultimately dictates the quality of life. Conclusions This concise overview of OBS literature highlights the importance of pre‐operative, peri‐operative, and post‐operative aspects with regards to the optimization of patient care. To achieve the best results, meticulous attention should be paid in all these areas, surgical and multi‐disciplinary. Patient education and counseling, with shared decision making are central to the success of the procedure.

Engineering pedicled vascularized bladder tissue for functional bladder defect repair

“…25 The first clinical bladder substitution by a bowel segment can be traced back to 1913, and it has become a standard method in clinical treatment. 26 The ileum is most frequently used due to its better compliance and less contractility compared with other segments. However, this kind of method not only requires the sacrifice of autologous intestinal segments but also results in large amounts of complications.…”

“…Late complications involve urolithiasis, ureterointestinal stricture, renal function decline, metabolic disorder, urinary incontinence, urinary retention, and sexual dysfunction. 26 Thus, there is an urgent need for a new strategy for bladder reconstruction with less invasion and complications.…”

Comparative performance of the different orthotopic urinary diversions

“…Metabolic disturbances and electrolyte abnormalities vary depending on which segments of the bowel are used for diversion rather than the pouch configuration. Both the ileum and colon can produce hyperchloremic metabolic acidosis [8]. The risk of metabolic acidosis is higher in neobladder compared to ileal conduit patients given the longer contact time between urine and bowel mucosa [27].…”

“…Colon is no longer used for orthotopic neobladder construction due to the unfavorable outcomes [7]. Ileum or combined ileum and colon are the preferred bowel segments given their greatest compliance and lowest likelihood of generating intermittent high-pressure contractions [8]. A brief overview of the orthotopic neobladder reconstruction techniques is provided in Table 1.…”

BJUI Compass 2021 year‐end review

“…For the November 2021 BJUI Compass , we have nine articles … To the Journals … The narrative review by Thakare et al 1 encompassed 1970–2020 articles on orthotopic bladder substitution for patients undergoing cystectomy. The paper highlights the full pathway of preoperative planning, intraoperative results, and postoperative management.…”