Cystectomy Orthotopic Neobladder

A cystectomy with orthotopic neobladder is the removal of the urinary bladder (most commonly for bladder cancer) with construction of a new bladder, termed a neobladder, made from a portion of the patient’s bowel. The neobladder can be attached to the native urethra, and the patient can void through the urethra with a nearly normal voiding pattern.

Orthotopic Neobladder: When it is the Best Choice?

This diversion is reserved for carefully selected patients who:

• Those with: - muscle-invasive or high-risk bladder cancer
• Cancer-free urethra 
• Normal renal function 
• Good liver and bowel function 
• They need to be physically and mentally able to train their bladder post-surgery 

It is usually not recommended in those with urethral involvement, severe renal failure, or profound bowel disease.

Benefits of an Orthotopic Neobladder

• No external stoma or bag required
• Nearly normal urination down the urethra again
• Improved body image and quality of life in a small group of patients
• Sexual and social confidence remain intact in many

Orthotopic neobladder cystectomy

The orthotopic neobladder cystectomy is a reconstructive urological surgical procedure which involves removal of the diseased urinary bladder along with the construction of new bladder using the patient’s intestine, joined to the native urethra so as to enable near-normal micturition. 

Procedure:

Preoperative Preparation 

• Key preoperative considerations include Detailed imaging (CT/MRI abdomen–pelvis) 
• Cystoscopy and biopsy to confirm diagnosis 
• Renal function tests, electrolytes, liver function 
• Bowel preparation (selective) 
• Urethral frozen section (to confirm cancer-free urethra) 
• Counselling on continence and bladder training 

Radical Cystectomy 

• Urinary bladder completely excised 
• Men: bladder, prostate, seminal vesicles 
• Women: bladder, uterus, ovaries, anterior vaginal wall (organ-sparing approaches may be possible) 
• Pelvic lymph node dissection is performed concurrently 

Intestinal Segment Isolation 

• A 50–60 cm length of the ileum (small bowel) is isolated 
• Continuity of bowel is re-established with staplers or sutures 
• Blood supply to the intestinal segment is maintained 

Neobladder Construction 

• The ileal segment is detubularized (unfolded along its side) 
• It is reshaped into a low-pressure spherical reservoir 

Other common techniques are: 

• Studer neobladder 
• Hautmann neobladder 
• Modified ileal neobladder techniques 

Ureteric Implantation 

• Both ureters are implanted into the neobladder 
• Anti–reflux or refluxing techniques can be adopted 
• Temporary ureteric stents are placed 

Urethral Anastomosis 

• The neobladder is attached to the native urethra 
• This permits voluntary voiding via the urethra 
• A urethral catheter is placed to aid healing 

Drainage and Closure 

• Pelvic drains are placed 
• The abdominal incision is closed (open/laparoscopic/robotic) 

Operative Time & Length of Stay 

• Surgery time: 6–9 hours 
• Length of stay: 7–14 days 
• Catheter removal: 2–3 weeks post-cystogram

Radical cystectomy neobladder

A radical cystectomy with neobladder formation is a complex urologic operation that entails total cystectomy with replacement by a new bladder, the neobladder, which is fashioned from a bowel segment. 

When the neobladder is connected to the native urethra, it is called an orthotopic neobladder. 

Indications

This procedure is done for:

• Muscle-invasive bladder cancer (T2 – T4a)
• High-risk non-muscle invasive bladder cancer not responding to BCG
• Selected benign bladder conditions (rare) 

Patient selection criteria:

• Urethra is cancer free
• Good renal function.
• No severe liver or bowel disease
• Good motivation and ability for postoperative training.

Robotic cystectomy neobladder

Robotic cystectomy with neobladder constructionRARS is an advanced minimally invasive technique to remove the entire urinary bladder (radical cystectomy) and create a new bladder (orthotopic neobladder) - commonly from a portion of the small bowel - which is then attached to the urethra to permit near-normal urination.

Who is a Suitable Candidate?

This method is used for the patients who:

• Have muscle-invasive bladder cancer or high-risk NMIBC
• Have a cancer-free urethra.
• Have adequate kidney and liver functions.
• No significant bowel disease.
• Are motivated for postoperative bladder training.

Benefits of the Robotic Technique

• Reduced blood loss and transfusion requirements
• Smaller incisions, less pain after surgery
• More rapid recuperation of bowel function
• Reduced length of hospitalization
• Reduced risk of recurrence and similar survival following open surgery in experienced hands.

Cystectomy neobladder recovery

The restoration of health following robotic radical cystectomy with neobladder is progressive and takes place in stages. Recovery of full function usually requires 3 to 12 months, with the time needed dependent on age, fitness, and compliance with rehabilitation. 

Post-Op Early Period (Days 1–7)

• Hospital Stay: 7-14 days

What To Expect:

• ICU/high-dependency unit 24 to 48 hours 
• Pain management with epidural or IV analgesic 

Multiple tubes: 

• Urethral catheter 
• Ureteric stents 
• Abdominal drains 
• Gradual return of bowel motility (gas → liquids → soft food) 
• Early ambulation to prevent complications 

Early Recovery Phase (Weeks 2–6) 

At home 

• Urethral catheter generally remains in place for 2 to 3 weeks 
• Cystogram performed prior to catheter removal 
• Light walking is encouraged 
• No heavy lifting or straining 

Neobladder adaptation 

• Neobladder has low capacity at the start 
• Urine can have mucus (it's normal) 
• Timed voiding (every 2 to 3 hours, even at night) 

Intermediate Recovery (2 to 6 Months) 

Bladder training 

• Increasing intervals for voiding 
• Pelvic floor (Kegel) exercises begin 
• May need nighttime alarms 

Continence 

• Daytime continence improve first 
• Nighttime incontinence is very common at first 
• Bladder control is well established in most patients by 3 to 6 months 

Activity 

• Work schedule: 6 to 8 weeks (desk job) 
• Driving generally at 4 to 6 weeks 

Recovery Over the Long Term (6-12 months) 

Functional results 

• Capacity of neobladder increases 
• Improved control of urine 
• Decreased need for pads 
• Some patients may have to perform intermittent self-catheterization 

Lifestyle 

• Nearly-normal activities of daily Life 
• Continuing bladder training 
• Proper hydration is important 

Diet During Recovery 

• High protein diet for repair 
• Small, frequent meals to start 
• Adequate fluids
• Check electrolytes 
• You may need Vitamin B12 supplements for a long time.

Orthotopic neobladder complications

Postoperative problems following an orthotopic neobladder are classified as early (short-term) and late (long-term) complications. The majority of them can be handled by early diagnosis and appropriate monitoring.

Initial Complications (Within the First Month) 

• Urine Leak
• Infection
• Ileus / Bowel Obstruction
• Bleeding
• Thromboembolism

Late Complications (After 30 Days)

• Urinary Incontinence
• Urinary Retention
• Ureter–Neobladder Stricture
• Metabolic Complications
• Deficiency of B12
• Recurrent Urinary Infections

Best hospital cystectomy neobladder India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

An orthotopic neobladder after a/radical cystectomy has become a standard and suitable urinary diversion that enables selected patient to void per urethra without an external stoma. Although the operation is complex and specific early and late complications do occur, the majority of complications are predictable, treatable, and tend to improve with time in carefully selected and closely followed patients. The criteria for success (oncologic safety, surgical skill, patient motivation, and follow-up) are well defined. With appropriate bladder training, pelvic floor rehabilitation, and administering routine renal and metabolic surveillance, most patients achieve good continence, quality of life is maintained, and functional results are durable.

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FAQ

1. How do you urinate after neobladder surgery?

• Neobladder patients urinate by relaxing the pelvic floor and straining with light abdominal pressure, since the neobladder does not have any natural bladder contractions. 

2. Is catheterization permanent?

• Permanent catheterization is not necessary for the majority of patients, but in several cases patients are required to perform intermittent self-catheterization due to incomplete evacuation of the neobladder.

3. Is it normal to have mucus in your urine?

• Yes. The neobladder is constructed from intestine, which makes mucus. This is normal and usually goes down with hydration.

4. Is robotic neobladder surgery better than open surgery?

• Both allow for similar cancer control. The advantages of robotic surgery are usually less blood loss, smaller incisions, and a quicker recovery if you have an experienced surgeon.

5. How long does a neobladder last? 

• A neobladder is intended to last a lifetime unless regular follow-up is neglected or proper care is not taken.