THE ILEAL NEOBLADDER - UPDATED EXPERIENCE WITH 306 PATIENTS

From April 1986 through May 1995, 306 men with primary urothelial carc inoma underwent radical cystoprostatectomy and orthotopic bladder subs titution via the ileal neobladder. Altogether, 7.5% of the patients su ffered general early complications, including thrombosis, embolism, wo und infection, and pneumonia. Specific early complications directly re lated to formation of the neobladder and requiring surgery included il eus (4%), abscess drainage (2%), and leakage of the ileal anastomosis (0.5%). The early reoperation rate was 6.5%. Early complications that required temporary percutaneous drainage were lymphocele formation (3% ) or ureteral obstruction (6%). In all, 9% of our patients required pr olonged catheter drainage for leakage of the ileouretheral anastomosis . Late complications requiring reoperation were ileus (2%), abscess dr ainage (1%), neobladder fistula to the colon (1,5%), ureteral reimplan tation because of obstruction (3.6%), and nephrectomy for hydronephros is (1%). A transurethral incision of the ileoureteral anastomosis was necessary in 7% of cases. Continence was separately addressed by sendi ng each patient and his home physician a detailed questionnaire: Using our criteria (no diapers, no awakenings) the night and day continence rate increased from 67% at 6 months, to 72% at 1 year, to 85% at 2 ye ars, finally reacting 90% after 4 years. In part II of this presentati on we address the question as to whether the option of orthotopic blad der replacement has any impact on the patient's and physician's decisi on toward earlier cystectomy. We compared our ileal neobladder cohort with a group of 137 patients that had been operated on during the same time span by the same group of surgeons. There was no negative select ion with regard of the tumor stage of our patients. However, as compar ed with the conduit group, the neobladder cohort had a significantly i mproved survival rate. This phenomenon is explainable by the significa ntly lower number of previous transurethral resections of the bladder (TUR-Bs) performed in the neobladder group. The time span between prim ary diagnosis and cystectomy was 10 months in the neobladder group as compared with 18 months in the conduit patients. These data reinforce our belief that orthotopic bladder replacement using the ileal neoblad der yields an extraordinary functional result that can be accomplished with a high degree of patient satisfaction and minimal complication. The availability of orthotopic bladder replacement does indeed stimula te the physicians and patients decision toward earlier cystectomy.