THE ILEAL NEOBLADDER CONNECTED TO THE FEM ALE URETHRA

Orthotopic reconstruction to the native urethra has revolutionized uri nary diversion, allowing patients to void per the urethra. This form o f urinary diversion was initially performed solely in male patients af ter cystectomy. More recently, however, with a better understanding of the female continence mechanism, including the urethral/vaginal suppo rt mechanism, and the ability to select appropriate female candidates properly for this type of surgery, orthotopic reconstruction has becom e a viable option in women. Since November 1986, 24 women aged 53 year s (range 17-76) have undergone orthotopic reconstruction using the ile al neobladder. Indications for cystectomy included transitional cell c arcinoma of the bladder (8), fibrotic radiated bladder (4), interstiti al cystitis (5), tuberculotic bladder (2), urge incontinence (2), neur ogenic fibrotic bladder (2), and fibrotic bladder of unknown etiology (1). Nineteen patients are available with a median follow-up of 48 mon ths (range 3 to 109 months). There were no perioperative deaths, with few early and late complications. Two women previously irradiated deve lopped a neovesicovaginal fistula and had to be diverted by an ileal l oop. Three patients from the far East are no longer available for foll ow-up. Ten years of experience with 24 patients have led to a nerve- a nd urethral-support-sparing cystectomy technique with the ileal neobla dder anastomosed to the proximal urethra. However, even then, retentio n in 20 % of the patients rather than the expected incontinence is the critical issue. Incontinence has never been a problem. The advent of orthotopic lower urinary reconstruction in women is a major achievemen t in the evolution of urinary diversion. With our increasing understan ding of the continence mechanism in women and with increasing evidence that the female urethra can be safely preserved after cystectomy, ort hotopic lower urinary tract reconstruction by the ileal neobladder can now be offered safely not only to males, but also to female patients undergoing cystectomy, and the functional results are superb.