129

ILEONEOBLADDER

(HAUTMANN TYPE) 13BOWEL DETUBULARIZATION ANDW FORMATION

FIG. 13-1. From a point 20 cmproximal from the ileocecal valve,60 to 70 cm of the bowel is mea-sured. This segment and its mesen-tery are divided to accommodateits placement in the pelvis. Thebowel is reanastomosed posteriorto the ileoneobladder segment.

FIG. 13-2. The 60 to 70 cm smallbowel segment is folded into a Wformation and temporarily fixedwith 2-0 stay sutures (1). The rightarm of the W formation (2) shouldbe longer and should be placedlower than the left arm since itwill be used as the neobladderneck to be anastomosed to the dis-tal urethral stump.

After the bowel is opened andcleared of its contents by saline so-

lution irrigation, it is divided at itsantimesenteric line (3) for detubu-larization. The surgeon places theleft index finger within the lumenand maintains tension against theantimesenteric line of the bowelwhile the right hand applies theBovie cutter to open the bowel.

At the lower arm of the W for-mation, the detubularization is notperformed at the antimesentericline. At this point it is critical thatthe surgeon divide the bowelheading toward the mesentericside, thus creating a lip or a flap atthe lowermost part of the W for-mation (4). This lip of extra tissuewill be important not only to cre-ate the neobladder neck but alsoto add extra length to reach thedistal urethral stump with this Wformation.1

13-1

13-2

Ileum

20 cm

Cecum

60-70 cmModified W Formation

4

3

2

1

Line of incision

Lower segment

Ileal segment

Site of bladderneck construction

Stay sutures

•

3Line of incision

Ileum

Mesentery

Division of Ileum

Indexfinger

Line of incision

3

130 Critical Operative Maneuvers in Urologic Surgery

FIG. 13-3. The edges of the di-vided bowel are sewn together(A). The simplest and fastest ap-proach is to perform a continuousstitch (2-0 Vicryl) using an atrau-matic straight needle (Davis &Geck). An alternative maneuver isto use a “quick reloading” tech-nique with a half-circle needle(see p. 122). Absorbable staplesare awkward to apply and not ef-ficient for the creation of thisneobladder.

For the neobladder neck, thereare two reconstructive options: atthe lowermost W configuration ofthe neobladder, the surgeon can(1) simply puncture the lip (B) or(2) create a neobladder neck by

sewing together the cut edges,thus gaining another 2 to 3 cm inlength and bringing the neckcloser to the distal urethral stump(C). We prefer the latter option. Iftension already exists when theneobladder is placed down intothe pelvis, this extra 3 cm can becritical in producing the desiredoutcome.

While checking for tension ofthe mesentery and the bladderneck when the neobladder is inthe pelvis, the surgeon shouldalso estimate the position ofureterointestinal anastomoses onthe middle and left leaves of theW formation.

Distal urethral stump

Simple puncture

2-3 cm

Construction ofbladder neck

Location ofneobladder neck

•

Second leaf

Third leaf

Ileotomies for best position ofureterointestinal anastomoses

A

B C

13-3

Ileoneobladder

Excision of mucosaland submucosal layers

Le Duc Ureterointestinal Anastomosis

1/4- to 1/2-inch Penrosedrain for traction

Wide ileotomy forureterointestinalanastomosis

Cylindric support(Poole suctiondevice) under bowel

Cross-sectional View

Chapter 13 Ileoneobladder (Hautmann Type) 131

URETERAL DISSECTION

As previously discussed in thesection of radical cystectomy (seep. 85), the avascular line of Toldtis incised and both ureters are iso-lated. We continue the right in-cision around the cecum and upthe mesenteric root. This maneu-ver makes the left ureteral tunnel-ing much easier and shorter (seep. 85).

As in all urinary diversions,whether an ileal conduit, conti-nent pouch, or neobladder, themore difficult ureteral anastomo-sis is always the left side. There-fore the surgeon should makesure that the left ureter and its ad-ventitia are free up to the level ofthe lower pole of the kidney. Theposterior parietal peritoneal tun-nel must be wide enough to avoidany ureteral angulation, and theinferior mesenteric artery shouldnot obstruct the passage of the leftureter to the right side. Some sur-geons bring the ureter anterior tothe peritoneum, but we prefer theperitoneal tunneling approach.2,3

By the time the cystectomy hasbeen completed, the ureters willhave become dilated with hydro-nephrosis if clipped as soon as theureters are divided. This maneu-ver not only makes the ureteroin-testinal anastomoses easier butalso prevents the ureters fromtwisting.

URETEROINTESTINALANASTOMOSES

It is important that the surgeonestimates the best position of theureteral implantation while theneobladder is down in the deeppelvis.

In general, the left ureter isbrought in on the left segment,whereas the right ureter is broughtin on the middle segment of the Wformation (see Fig. 13-3, A). It isbetter to make the ureteral entrytoo high than too low in the neo-bladder, thus avoiding ureteral ten-sion, especially of the left ureter.

LE DUC URETEROINTESTINALANASTOMOSIS

The left ureterointestinal anas-tomosis should be completed firstbecause it is the more difficult toperform.

FIG. 13-4. The puncture of theneobladder for the ureteral im-plantation must be wide enoughso that the ureter can slide backand forth freely. A common erroris to make this puncture too small.

While the assistant applies trac-tion upward on a 1⁄4- to 1⁄2-inch (0.5to 1 cm) Penrose drain throughthe puncture site, the surgeon se-cures the thumb and index fingerover the bowel segment, which iswrapped around a cylindric tube(i.e., Poole suction device).

After injecting saline solutioninto the mucosa, the surgeon cutsaway a trough of mucosal andsubmucosal tissues.

13-4

Fixationstitches

Ureterointestinalanastomosis

Stent with mucosalfixation stitches

Mucosa UreterA

B

C

Alternative Methods ofMucosoureteral Approximation

(Cross-sectional Views)

132 Critical Operative Maneuvers in Urologic Surgery

FIG. 13-5. The ureter is broughtthrough the intestinal puncturesite and fixed on both the serosaland the mucosal sides to preventretraction. The surgeon must avoidstrangulation of the ureteral vascu-lature by these fixation stitches.

FIG. 13-6. The spatulated ureteralmeatus is fixed to the intestinaltrough with deep stitches (4-0Vicryl) and a Bard diversionarystent (8 Fr) is passed up to the kid-ney (A). The stents are fixed to theileoneobladder with stitches (4-0chromic).

According to Le Duc,4,5 thereare two options for mucosoure-teral antirefluxing fixation. The in-testinal mucosa can be approxi-mated against the two sides of theureter (B) or, if there is redundantintestinal mucosa, the two edgesof the mucosal layer can be ap-proximated over the ureteral seg-ment (C).

Ureter

Ureteral fixationstitches at

ileotomy site(serosal side)

Ileoneobladder

Ureteral fixationstitches (mucosal side)13-5

13-6

Chapter 13 Ileoneobladder (Hautmann Type) 133

NEOBLADDER NECK AND DISTALURETHRAL STUMPAPPROXIMATION

FIG. 13-7. Before the neobladderis placed into the pelvis for theneobladder neck–urethral anasto-mosis, the distal half of the neo-bladder should be reapproxi-mated with a running stitch (2-0Vicryl) because it will be impossi-ble to close once it is in the deeppelvis (A).1,6

A Malecot catheter (24 or 26 Fr)is inserted at the top of the neo-bladder, and stents are broughtthrough separate stab wounds orthrough the incision line. The up-per half of the neobladder is leftopen until the neobladder neck–urethral anastomosis is completed(B).

NEOBLADDER NECK–URETHRALANASTOMOSIS

A Foley catheter (18 Fr with 5ml balloon) is passed from theurethral meatus through theneobladder neck.

Four to six anastomotic stitches(2-0 Vicryl) are placed circumfer-entially but are not tied.

The Foley catheter balloon is in-flated to 10 to 15 ml, providingsufficient but not excessive trac-tion to tie the anastomotic suturesdown.

After inspection of all anasto-moses, the upper half of the neo-bladder is closed. With the Foleycatheter clamped shut, saline so-lution is infused through theMalecot catheter to fill the neo-bladder so that leakage at the su-ture lines can be checked.

Partial ilealreapproximation

performed first

Neobladderneck

A

Distalurethral

stump

Stents

Completereapproximationafter bladderneck—urethralanastomosis

Neobladder

B13-7

134 Critical Operative Maneuvers in Urologic Surgery

K E YP O I N T S

� A small bowel segment 60 to 70cm in length is used to create thepouch.

� The bowel is reanastomosed pos-terior to the neobladder.

� A W formation of the smallbowel is constructed with an ex-aggerated droop of the right armto serve as the bladder neck.

� In detubularization, a flap or lipis constructed at the most depen-dent position of the W formation(right) for the neobladder neck–urethral anastomosis.

� The left ureter must be free allthe way to the lower pole of thekidney and tunneled behind theposterior parietal peritoneum.

� The location of the ureterointesti-nal anastomoses must be esti-mated.

� The distal half of the ileo-neobladder should be closed be-fore the distal neobladder neck–urethral anastomosis is per-formed. A Malecot catheter isplaced proximally, and the stentsare inserted.

� A Foley catheter (18 Fr with a 5ml balloon) is passed through theneobladder neck, and the anasto-motic stitches are placed.

� The remaining open portion ofthe proximal neobladder is closed.

P O T E N T I A LP R O B L E M S

� Diseased small bowel: Use an Indi-ana pouch or ileal loop conduitdiversion

� Neobladder does not reach urethralstump: Check for asymmetric Wformation with lower right arm→ create a bladder neck by anas-tomosis of the intestinal flap, ifnecessary

� Left ureter is under tension: Freeureter up to the kidney → ensurethat posterior peritoneal dissec-tion has no sharp angles

� Inferior mesenteric artery syndrome(see p. 65): Consider bringingthe ureter to the anastomotic sitevia an anterior position ratherthan through a retroperitonealtunnel

REFERENCES1 Fair WR: Personal observations and

communications, May 1995.2 Hautmann RE et al: The ileal

neobladder: 6-years’ experience withmore than 200 patients, J Urol 150:40,1993.

3 Miller K et al: The ileal neobladder:operative technique and results, UrolClin North Am 18(4):623, 1991.

4 Le Duc A, Camey M, Teillac P: Origi-nal antireflux uretero-ileal implanta-tion technique: long-term follow-up,J Urol 137:1156, 1987.

5 Le Duc A: Mucosal groove antirefluxuretero-ileal implantation. In Hohen-fellner R, Wammack R, editors: Soci-eté internationale d’urologie reports: con-tinent urinary diversion, London, 1992,Churchill Livingstone.

6 Fair WR: The ileal neobladder, UrolClin North Am 18(3):555, 1991.

SUGGESTED READINGHautmann RE et al: The ileal neoblad-

der, J Urol 139:39, 1988.