Introduction:
Orthotopic neobladder reconstruction is another name for neobladder reconstruction. When the bladder is not working efficiently, the surgeon constructs a new bladder and attaches it to the urethra to facilitate the passage of urine. A long ago, Dr. Faud Freiha developed the 'Stanford pouch’, the earliest variation of the neobladder reconstruction procedure. The technique to do the procedure has varied over time.
What Is a Neobladder Reconstruction?
Neobladder reconstruction means a new bladder construction. The surgeon excises a part of the small intestine to reconstruct the new bladder and attaches it to the urethra to exit the urine. It is constructed in the shape of a pouch and is positioned at the place of the urinary bladder. So that one can urinate voluntarily.
Why Is It Done?
It is done in the case of a failed function of the urinary bladder. The patient may be suffering from an aggressive form of bladder cancer; in such cases, the diseased bladder is removed (also known as cystectomy), and neobladder reconstruction is done. There are several other reasons behind neobladder reconstruction, such as neurological conditions, radiation therapy, and other diseases. Incontinence of urine, that is, losing control over urination, can be one of the reasons. Any trauma to the urinary bladder can also lead to neobladder reconstruction.
What Happens in Surgery?
Before surgery, the surgeon orders tests to check the patient’s kidney function and ensure that the patient does not have a urinary tract infection. They may also prescribe imaging tests, such as a CT (computed tomography) scan, of the urinary tract to check the ureters to see if they are in good condition. The cystectomy (bladder removal) will be done under general anesthesia and will take approximately two to six hours. There can be other alternatives to cystectomy. Usually, the surgeon uses part of the patient’s small bowel to make a new bladder. They take a piece of small intestine and join the cut ends of the small intestines. They also repair the small intestine. They use the work of the small intestine to make a pouch inside the patient’s body. This is called a neobladder. The small intestine is given the shape of the urethra, the ureter. They then place the neobladder at the site of the urinary bladder. The small intestine is given the shape of the urethra, the ureter. Then, broad-spectrum antibiotics are given to the patient to avoid any kind of infection.
What Precautions Are Taken After the Surgery?
The patient has to stay in the hospital for a few days after the surgery. The neobladder may feel unnatural or different. The patient is told to empty the bladder more often. The neobladder may leak if heavy objects are present. If any other inconvenience occurs, the patient needs to see their physician as soon as possible. Usually, the patient is given basic training on how and when to empty the neobladder. A catheter and a suprapubic catheter remain until the healing occurs. After some time after the surgery, anastomotic leaks have to be ruled out. Leaks can be identified by palpating or sensing the decrease in the monitored urine output and an increase in pelvic drain output. A cystogram is performed to see if everything is intact and healing. After the post-operative phase, patients must learn the neobladder emptying process and intermittent self-catheterization, as it may be needed sometimes. As a neobladder is an artificial route of emptying urine, a patient must learn the Valsalva maneuver and pelvic floor relaxation to avoid urine. The post-operative phase also includes training for distending the bladder so that it may retain a large amount of urine. The general post-operative phase suggests no driving, sexual activity, or lifting heavy objects for about two to four months.
What Are the Risks That May Occur After Neobladder Reconstruction?
There are several risks or complications associated with neobladder reconstruction.
They are mentioned as follows:
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Retention of urine.
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Incontinence.
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Gastrointestinal Infections.
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Bleeding.
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Deep vein thrombosis (DVT). It is a condition when a blood clot also known as thrombus forms in one or more of the deep veins in the body, usually in the legs.
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Wound-related complications.
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Intestinal anastomotic leak. This happens when the two ends of a channel that are connected together are sealed incompletely, and leakage of the contents inside can be seen.
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Voiding dysfunction. This occurs when there are abnormalities present in the storage, filling, and emptying of the urine.
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Calculi formation. Development of the stones, made of calcium, oxalate, cystine, xanthine, uric acid, and phosphate.
What Changes Occur in Daily Life After Neobladder Reconstruction?
Usually, in terms of bladder cancer, chemotherapy is given after the cystectomy if metastasis occurs. After healing, many changes come into the patient’s daily activities. The person may need access to the washroom to empty the bladder at the job. The patient would be unable to lift heavy objects as it may lead to urine leaks. Also, may observe low stamina and a decreasing urge to go out and meet new people. Any situation can arise where the patient has to use a toilet or any kind of leak that would lead the patient to an embarrassing moment. The patient may have problems with the sex life. The amount of liquid the patient consumes should be actively monitored as it may lead to frequent urination.
Who Is Suitable for the Reconstruction?
There are several situations and contraindications before considering the patient suitable for reconstructing the neobladder. Many complications related to the renal and intestinal systems are also considered. During patient selection, an overview of everything, such as expected risks and complications, comorbidities, and the discipline of the patient to maintain the neobladder, is observed. The indications, considerations, and contraindications will be explained to the patient properly.
Conclusion:
Radical cystectomy reconstruction is a challenging procedure with a significant risk of short and long-term complications. The complications must be addressed. The technique is gaining popularity and should be offered to patients while considering oncological and patient factors. It is important to manage patients’ expectations and ensure they are committed during the postoperative period. Robotic-assisted radical cystectomy is gaining popularity, and although technically challenging, intracorporeal neobladder reconstruction is routinely performed in select centers. All patients with neobladder reconstruction should have regular long-term follow-ups for oncological surveillance and to identify complications should they arise. The most common complication is diversion-related. The care for elderly patients with comorbidities is challenging. An alteration in life comes into existence. Nevertheless, the procedure is still evolving regarding the surgical process and patient rehabilitation.
