What is neobladder reconstruction and who is a suitable candidate for the procedure?

Neobladder Reconstruction: Definition and Patient Selection

Neobladder reconstruction is an orthotopic urinary diversion procedure where a continent urinary reservoir is created from intestinal segments (typically ileum) and connected to the native urethra, allowing patients to void naturally after radical cystectomy for bladder cancer. 1

What Is Neobladder Reconstruction?

Neobladder reconstruction involves creating an internal urinary reservoir using gastrointestinal tissue (most commonly ileum) that is anastomosed to the urethra, enabling patients to urinate through their native urethra rather than requiring an external stoma. 1, 2 This procedure is performed following radical cystectomy and provides the closest approximation to native bladder function, though with increased risk of nighttime incontinence and potential need for intermittent self-catheterization. 1

The procedure represents a quality-of-life-focused alternative to ileal conduit diversion, avoiding the cosmetic, psychological, and practical complications associated with an external stoma. 3, 4

Absolute Contraindications

Do not offer orthotopic neobladder to patients with invasive tumor in the urethra or at the level of urethral dissection. 1 This is a strong, non-negotiable contraindication based on oncological safety. 5

Specific Exclusion Criteria:

• Positive urethral margin on intraoperative frozen section analysis 1, 5
• Invasive urethral tumor prior to cystectomy 1
• Tumor involvement at the prostatic urethra or bladder neck in men (requires absence of tumor at these sites) 1
• Tumor in the area to be preserved in women (anterior vaginal wall or bladder neck involvement) 1

Relative Contraindications Requiring Careful Assessment

Carcinoma in situ (CIS) in prostatic ducts or bladder neck is a relative contraindication that requires careful patient selection, regular follow-up cystoscopy, and urinary cytology monitoring. 1 Non-muscle-invasive bladder cancer (NMIBC) in the prostatic urethra or bladder neck does not necessarily preclude neobladder if rigorous surveillance is maintained. 1

Suitable Candidates: Selection Algorithm

Step 1: Oncological Eligibility

Confirm absence of urethral/bladder neck tumor involvement through intraoperative frozen section analysis. 1, 5

• In women, preoperative bladder neck involvement is an important risk factor (approximately 12% have urethral involvement), but not an absolute contraindication if intraoperative frozen section is negative. 1
• Urethral tumor involvement occurs in approximately 12% of female patients with high-grade invasive urothelial carcinoma. 1
• Organ-confined disease is preferred for optimal outcomes. 1

Step 2: Functional Requirements

Select patients based on:

• Adequate renal and liver function to tolerate surgery and manage metabolic consequences of intestinal urinary diversion 6, 3, 4
• Good manual dexterity for potential intermittent self-catheterization 5, 4
• Cognitive competence to understand and comply with neobladder training protocols 2, 4
• Available gastrointestinal tract for reconstruction (no prior extensive bowel surgery or radiation) 6

Step 3: Patient Motivation and Preferences

Only offer neobladder to motivated patients who:

• Strongly desire to avoid an external stoma 5, 3
• Are willing to commit to rigorous neobladder training postoperatively 2, 3
• Accept the risks of nocturnal incontinence (daytime continence achieved in ~70% initially, improving over time) 4
• Understand potential need for intermittent self-catheterization 1
• Are willing to undergo long-term surveillance 1

Step 4: Special Considerations for Sexual Function Preservation

In men seeking sexual function preservation, sexual organ-preserving cystectomy techniques can be combined with neobladder reconstruction. 1 However, this requires:

• Organ-confined disease 1
• Absence of tumor at the prostate, prostatic urethra, or bladder neck 1
• Very high patient motivation 1
• Careful patient counseling and monitoring 1

Postoperative potency ranges from 80-90% for prostate-sparing, 50-100% for capsule-sparing, and 29-78% for nerve-sparing techniques. 1 Urinary continence ranges from 88-100% daytime and 31-96% nighttime. 1

In women, sexual organ-preserving techniques should be offered to preserve sexual function when there is absence of tumor in the area to be preserved. 1

Critical Counseling Points

Before radical cystectomy, fully inform patients about benefits and potential risks of all urinary diversion alternatives, with the final decision based on balanced discussion between patient and surgeon. 1, 5

Key Discussion Points:

• Quality of life: Sexual activity independently impacts global QoL and should be assessed pre- and post-operatively. 7 Patients with neobladders have comparable or better sexual function and QoL compared to ileal conduit patients. 3
• Metabolic complications: Risk of electrolyte abnormalities, metabolic acidosis, bone demineralization, and urinary calculi from intestinal segment use 4
• Nutritional deficiencies: Potential vitamin B12 deficiency requiring annual monitoring 1
• Continence expectations: Daytime continence ~70% initially, improving over years but may decrease after 20 years 4
• Urethral recurrence risk: Low but requires long-term follow-up with urethral wash cytology every 6-12 months, particularly if CIS was present 1

Common Pitfalls to Avoid

• Inadequate patient selection: Offering neobladder to patients with poor manual dexterity or cognitive impairment leads to poor functional outcomes 5, 4
• Insufficient preoperative counseling: Patients must understand the commitment to neobladder training and potential complications 1
• Ignoring frozen section results: Proceeding with neobladder despite positive urethral margins compromises oncological outcomes 1, 5
• Overlooking bladder neck involvement in women: While not absolute contraindication, requires intraoperative frozen section confirmation 1