How to Obtain Good Results with Orthotopic Bladder Substitution: The 10 Commandments



      The orthotopic neobladder has not only withstood the test of time but is increasingly becoming a more desirable method of urinary diversion. Complementing orthotopic neobladder features with adequate training allows patients to return to a urinary routine that is close to, if not completely, normal.


      The preconditions, indications, and contraindications as well as the key points of the surgical technique will be presented by researchers who pioneered this operation.

      Evidence acquisition

      Experience with and long-term follow-up of orthotopic reconstruction is presented by surgeons at institutions that pioneered orthotopic reconstruction during the last 25 yr with a high surgical volume of radical cystectomy (RCX) and any form of urinary diversion (particularly orthotopic reconstruction).

      Evidence synthesis

      Ten commandments were developed for achieving good results with orthotopic bladder substitution: (1) The procedure should be performed by a high-volume surgeon; (2) do not overextend the indication; (3) experience with nerve-sparing radical prostatectomy and bowel surgery is mandatory; (4) use ileum whenever possible; (5) maximum detubularisation is a must; (6) use a stented, freely refluxive ileoureterostomy; (7) the low-pressure, compliant, freely refluxive reservoir is standard; (8) be aware of myriad potential complications; (9) a full armamentarium of diversion techniques must be available; and (10) meticulous follow-up must be guaranteed.


      Continence and voiding function following orthotopic bladder substitution are determined primarily by characteristics of the reservoir and by a preserved, innervated outlet mechanism. The reservoir should be detubularised and compliant with a low end filling pressure. Ileum seems to be superior to sigmoid or stomach, which can be used when necessary but with higher incontinence rates. Reflux prevention is not a major concern and does not justify the use of an antireflux mechanism with a high complication rate.


      To read this article in full you will need to make a payment


      Subscribe to European Urology Supplements
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Madersbacher S.
        • Möhrle K.
        • Burkhard F.
        • Studer U.E.
        Long-term voiding pattern of patients with ileal orthotopic bladder substitutes.
        J Urol. 2002; 167: 2052-2057
        • Hautmann R.E.
        Urinary diversion: ileal conduit to neobladder.
        J Urol. 2003; 169: 834-842
        • Montie J.E.
        Technique of radical cystectomy in the male.
        in: Marshall F.F. Kavoussi L.R. McAninch J.W. Peters C.A. Textbook of operative urology. W.B. Saunders Company, Philadelphia, PA1996: 396-407
        • Hemal A.K.
        • Abol-Enein H.
        • Tewari A.
        • et al.
        Robotic radical cystectomy and urinary diversion.
        Urol Clin North Am. 2004; 31: 719-729
        • Herr H.W.
        • Faulkner J.R.
        • Grossman H.B.
        • et al.
        Surgical factors influence bladder cancer outcomes: a cooperative group report.
        J Clin Oncol. 2004; 22: 2781-2789
        • Elting L.S.
        • Pettaway C.
        • Bekele B.N.
        • et al.
        Correlation between annual volume of cystectomy, professional staffing and outcomes.
        Cancer. 2005; 104: 975-984
        • Saigal S.
        • Gore J.
        • Polich S.
        • Litwin M.S.
        Trends in reconstruction after radical cystectomy in the Medicare population.
        J Urol. 2005; 173: 487
        • Kessler T.M.
        • Burkhard F.C.
        • Permenis P.
        • Danuser H.
        • Thalmann G.N.
        • Hochreiter W.W.
        Attempted nerve-sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatovesiculectomy and ileal orthotopic bladder substitution.
        J Urol. 2004; 172: 1323-1327
        • Hekal I.A.
        • El-Bahnasawy M.S.
        • Mosbah A.
        • El-Assmy A.
        • Shaaban A.
        Recoverability of erectile function in post-radical cystectomy patients: subjective and objective evaluations.
        Eur Urol. 2009; 55: 275-283
        • Kessler T.M.
        • Burkhard F.C.
        • Studer U.E.
        Clinical indications and outcomes with nerve sparing cystectomy in patients with bladder cancer.
        Urol Clin North Am. 2005; 32: 165-175
        • Hautmann R.E.
        • Stein J.P.
        Neobladder with prostatica capsule and seminal-sparing cystectomy for bladder cancer: a step in the wrong direction.
        Urol Clin North Am. 2005; 32: 177-185
        • Botto H.
        • Sebe P.
        • Molinié V.
        • Herve J.
        • Yonneau L.
        • Lebret T.
        Prostatic capsule and seminal-sparing cystectomy for bladder carcinoma: initials results for selected patients.
        BJU Int. 2004; 94: 1021-1025
        • Studer U.E.
        • Burkhard F.C.
        • Schumacher M.
        • et al.
        Twenty years experience with an ileal orthotopic low pressure bladder substitute—lessons to be learned.
        J Urol. 2006; 176: 161-166
        • Ali-El-Dein B.
        Oncological outcome after radical cystectomy and orthotopic bladder substitution in women.
        Eur J Surg Oncol. 2009; 35: 320-325
        • Chang S.S.
        • Cole E.
        • Cookson M.S.
        • Peterson M.
        • Schmidt J.A.
        Preservation of the anterior vaginal wall during female radical cystectomy with orthotopic urinary diversion: technique and results.
        J Urol. 2002; 168: 1442-1445
        • Abou-Elela A.
        Outcome of anterior vaginal wall sparing during female radical cystectomy with orthotopic urinary diversion.
        Eur J Surg Oncol. 2008; 34: 115-121
        • Studer U.E.
        • Danuser H.
        • Thalmann G.N.
        • Springer J.
        • Turner H.
        Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: long-term results of a prospective, randomized trial.
        J Urol. 1996; 156: 1913-1917
        • Mann F.C.
        • Bollmann J.L.
        A method for making a satisfactory fistula at any level of the gastrointestinal tract.
        Ann Surg. 1931; 93: 794-797
        • Salomon L.
        • Lugagne P.M.
        • Hervé J.M.
        • Lebret T.
        • Botto H.
        No evidence of metabolic disorders 10 to 22 years after Camey type I ileal enterocystoplasty.
        J Urol. 1997; 157: 2104-2106
        • Fiona C.
        • Burkhard C.
        • Kessler T.M.
        • Springer J.
        • Studer U.E.
        Early and late urodynamic assessment of ileal orthotopic bladder substitutes combined with an afferent tubular segment.
        J Urol. 2006; 175: 2155-2161
      1. Buzelin JM. Physiologie et explorations fonctionnelles de la voie excrétrice urinaire. Rapport au 87ème Congrès Français d’Urologie; Novembre 1993; Paris, France.

        • Botto H.
        • Hervé J.M.
        • Barré P.
        Entéroplastie détubulée en Z après prostato-cystectomie totale.
        Prog Urol. 1994; 4: 77-83
        • Konety B.R.
        • Allareddy V.
        • Herr H.
        Complications after radical cystectomy: analysis of population-based data.
        Urology. 2006; 68: 58-64
        • Donat S.M.
        Standards for surgical complication reporting in urologic oncology: time for a change.
        Urology. 2007; 69: 221-225
        • Volkmer B.G.
        • de Petriconi R.C.
        • Hautmann R.E.
        Lessons learned from 1000 ileal neobladders: the early complication rate.
        J Urol. 2009; 181: 142
        • Lebret T.
        • Hervé J.M.
        • Barré P.
        • Lugagne P.M.
        • Barbagelatta M.
        • Botto H.
        Urethral recurrence in transitional cell carcinoma of the bladder. Predictive value of preoperative latero-montanal biopsies and urethral frozen sections during prostatocystectomy.
        Eur Urol. 1998; 33: 170-174
        • Thurairaja R.
        • Burkhard F.C.
        • Studer U.E.
        The orthotopic neobladder.
        BJU Int. 2008; 102: 1307-1313
        • Hautmann R.E.
        • Volkmer B.G.
        • Schumacher M.C.
        • Gschwend J.E.
        • Studer U.E.
        Long-term results of standard procedures in urology: the ileal neobladder.
        World J Urol. 2006; 24: 305-314