e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 8 5 6 – 8 6 4862

Greg Shaw*

Trisha Purkiss

R. Tim D. Oliver

Department of Medical Oncology,

St Bartholomew’s Hospital,

London, United Kingdom

David M. Prowse

Institute of Cell and Molecular Science,

Barts & The London, Queen Mary’s School of Medicine & Dentistry,

Queen Mary, University of London, London, United Kingdom

*Corresponding author

E-mail address: gregshaw@doctors.org.uk

August 29, 2006

Published online ahead of print on October 10, 2006

doi:10.1016/j.eururo.2006.08.053

DOI of original article: 10.1016/j.eururo.2006.04.021

Re: Udo Nagele, Markus Kuczyk, Aristotelis G.Anastasiadis, Karl-Dietrich Sievert, Jorg Seiboldand Arnulf Stenzl. Radical Cystectomy andOrthotopic Bladder Replacement in Females,Eur Urol 2006;50:249–257

We read with great interest the article published byNagele et al. on orthotopic urinary diversion inwomen (Eur Urol 2006;50:249–57). In this article, theauthors summarize their long years of experience inthe technical implementation of this surgical pro-cedure that, for more than 15 yr, has also beenapplied in patients with diagnosed bladder cancer.

The authors suggest a reconstruction procedureusing 40 cm of the terminal ileum to create aU-shaped orthotopic reservoir. A segment of thereservoir is adapted prior to detubularization, asfirst described by Abol-Enein, and formed intoa serosa-lined extramural tunnel in the furthercourse of the operation [1]. For reflux prevention,the ends of both ureters are passed through thistunnel.

The authors justify their choice of this type ofafferent reflux prevention by citing a low stricturerate described by Abol-Enein [2]. Despite this refer-ence, the question arises as to the outcome, in termsof reflux prevention and stricture rates, outside theclinic of the author who developed the technique.

Moreover, there is the basic question of whetherpatients profit from the intended reflux preven-tion. The majority of currently available studiesrecommend reflux prevention for continent cathe-terizable reservoirs [3].

However, the data status differs for orthotopicbladder replacement. The majority of publishedstudies point out that reflux prevention for anorthotopic reservoir is not advantageous in terms ofprotecting the upper urinary tract [4,5]. Such aprocedure is questionable because antirefluxiveimplantation techniques compromise the bloodsupply to the distal ureter or tubular segments

and thus tend to have a higher stricture rate thanrefluxive implantation.

Similar results were obtained at our clinic in afollow-up of 27 patients with orthotopic bladderreplacement and a wall-integrated tubular seg-ment. Contrast reservoirography showed that thisprocedure achieved sufficient reflux prevention inonly 16 of the patients. Despite this inadequatereflux prevention, the two groups did not differ interms of upper urinary tract infections, resultsof renal sequence scintigrams, or creatinine clear-ance values during a median follow-up of >2 yr.However, antirefluxive implantation led to a mark-edly higher stricture rate (7.1%) than refluxiveimplantation techniques reported in the literature(2–3%) [4,5].

These results as well as the cited publications ledus to question the suitability of antirefluxivetechniques for orthotopic urinary diversion.

References

[1] Abol-Enein H, Ghoneim MA. Optimization of uretero-

intestinal anastomosis in urinary diversion: an experimen-

tal study in dogs. III. A new antireflux technique for ure-

tero-ileal anastomosis: a serous-lined extramural tunnel.

Urol Res 1993;21:135–9.

[2] Abol-Enein H, Ghoneim MA. Functional results of ortho-

topic ileal neobladder with serous-lined extramural uret-

eral reimplantation: experience with 450 patients. J Urol

2001;165:1427–32.

[3] Hautmann RE. Urinary diversion: ileal conduit to neoblad-

der. J Urol 2003;169:834–42.

[4] Minervini A, Boni G, Salinitri G, Mariani G, Minervini R.

Evaluation of renal function and upper urinary tract mor-

phology in the ileal orthotopic neobladder with no antire-

flux mechanism. J Urol 2005;173:144–7.

[5] Thoeny HC, Sonnenschein MJ, Madersbacher S, Vock P,

Studer UE. Is ileal orthotopic bladder substitution with an

afferent tubular segment detrimental to the upper urinary

tract in the long term? J Urol 2002;168:2030–4, discussion

2034.

e u r o p e a n u r o l o g y 5 1 ( 2 0 0 7 ) 8 5 6 – 8 6 4 863

Mark Schrader*

Kurt Miller

Charite Universitaetsmedizin Berlin, Department of Urology,

Hindenburgdamm 30, 12200 Berlin, Germany

*Corresponding author. Tel. +49 30 84452575;

Fax: +49 30 84452575

E-mail address: mark.schrader@charite.de

October 4, 2006

Published online ahead of print on October 19, 2006

doi:10.1016/j.eururo.2006.10.010

DOI of original article: 10.1016/j.eururo.2006.05.037

Reply to Dr Schrader and Dr Miller’s Letter to theEditor re: Udo Nagele, Markus Kuczyk, AristotelisG. Anastasiadis, Karl-Dietrich Sievert, Jorg Seibold,Arnulf Stenzl. Radical Cystectomy and OrthotopicBladder Replacement in Females. Eur Urol2006;50;249–257

There are basically two ways to connect the uretersto an orthotopic intestinal urinary diversion. It ispossible to anastomose one or two ureters into anafferent (ileal) tubularised segment leading eithercontinuously or in a valvelike fashion into adetubularised intestinal reservoir, or the uretersare directly implanted to the detubularised intest-inal reservoir. By using an afferent tubular ileumsegment, it is possible to shorten the distal ureters,which may have the advantage from both theoncologic and the vascularisation standpoints.

Any afferent ileal segment longer than 15 cmserves, due to its peristalsis and possibly intra-abdominal pressure changes, as an antirefluxprotection of the upper urinary tract. Additionalantireflux protection of these tubular segments suchas intussusception or a subserosal imbedding of theileum at its insertion into the reservoir have beenabandoned by many institutions due to the pro-blems correctly mentioned by the authors, that is,compromise of the blood supply of the intussus-cepted or imbedded segments. Additional problemsof valve formation include incrustation and stoneformation due to the use of nonabsorbable materialssuch as staples.

Direct implantation of ureters, which failed at ahigher rate than the indirect, use the cuff nippletechnique [1] and the Le Duc-technique [2]. Theproblems with these techniques are the length of thedistal ureter, which may lead to devascularisation atthe side of the anastomosis, inadequate manipula-tion of the ureter itself, and exposure of the exteriorureteral wall, not covered by mucosa, to urine andsubsequently inflammatory stricture formation.

All of the above-mentioned techniques, includingthe simple afferent ileal segment longer than 15 cm[3], therefore, are some form of antireflux proce-dures. Using our reflux procedure would be there-

fore direct implantation of ureters into the reservoir,which is rarely done. We therefore replace anantireflux procedure consisting of, for example, a15-cm afferent tubular ileal segment by directsubserosal imbedding of ureters into the orthotopicneobladder. There are several advantages with thistechnique. We save at least 15 cm for one or twoafferent ileal segments, we do not rely on theperistalsis of ileum but have an antireflux procedurethat comes closer to the natural valve of the normalureterovesical junction, the chance of an extravasa-tion at the ureterointestinal anastomosis is mini-mal, and we have an easier access to the urinarytract for those patients with an orthotopic neoblad-der who may have problems in the upper urinarytract, such as stones, possibly recurrent tumours ofthe upper urinary tract, and the like, with theirincreasing life span after the neobladder procedure.Contrary to the technique described by Abol-Eneim[4] we use the Goodwin type of reservoir reconstruc-tion, which allows us to implant the conjoinedureters into a single subserosal tunnel. The locationof the ureteral neo-orifices is usually at the backwall, which makes the common ureteral plate moreeasily visible endoscopically.

A disadvantage may be that we have to preserve alonger distal ureteral segment. In a previous pub-lication, however, we have described a techniquebased on the vascular anatomy of ureters thatavoids devascularisation and stricture [5].

The Tuebingen variation of the orthotopic neo-bladder, performed open or laparoscopically, is ourpreferred method for both male and female patients.Regarding female patients, however, we think thatan efficient antireflux procedure may even be moreimportant due to a higher rate of residual urine andurinary retention compared to male patients [6].

In conclusion, almost all techniques published inrecent years for an orthotopic bladder substitutionuse some form of antireflux procedure. Our techni-cal variations for bladder substitution described inthe recent publication in this journal aim at using ashorter segment of bowel, a more natural imitationof the ureterovesical junction valve, prevention ofleakage, and better access from the neobladder to