Notes

Outline

Orthotopic Neobladder How I Do It

Neobladder: How I do it Patient Inclusion and Exclusion Criteria Psychosocial Able and willing to carry out CIC Good manual dexterity No urethral problems Compliant with F/U requirements Physiologic Hepatic Function: normal Renal Function: Cr < 2 or CrCl >40 with equal kidneys Intestinal Function: No Hx of IBD, Ca/polyps, XRT or extensive resection Age: <70yrs but individualized

Neobladder: How I do it Patient Inclusion and Exclusion Criteria Urethra (male) TUR Prostatic Fossa Avoid Orthotopic if any chips are + Urethrectomy if stromal or ductal invasion present Urethra (female) Biopsy  (cold cup) BN pre-op Exclude patients with > stage T3 disease Frozen section margin at cystectomy to r/o submucosal spread Tumor Stage Exclude patients with grossly + nodes Exclude patients with > stage T3 disease

Neobladder: How I do it Technical Points:  Male Cystectomy Nerve Sparing Procedure Urethral dissection/reconstruction (Eastham 96)

Neobladder: How I do it Technical Points:  Female Cystectomy Minimize surgery in areas of Hypogastric and pelvic plexus PLND Pouch of Douglas Conserve Innervation to Urethra Minimal dorsal vaginal excision in area of bladder - vagina contact Dissection of bladder pedicles close to bladder Use Foley balloon to identify bladder neck Frozen section on BN

Neobladder: How I do it Technical Points:  Female Cystectomy Close vagina perpendicular to incision Suspend pouch to prevent “pouchocele” Pelvic Sidewall Round Ligament Place Omentum below pouch reduce risk of fistulas reduce chance of “pouchocele”

Neobladder: How I do it Technical Points:  Female Cystectomy Urethral Rhabdosphincter (EUS) Mid to caudal urethra Not removed with proximal urethrectomy No sphincter is present at BN Urethral Epithelium Squamous epithelium in distal third Transitional epithelium in proximal third Epithelium merge in middle third

Neobladder: How I do it Technical Points:  Female Cystectomy Urethral Innervation Urethral innervation along lateral vaginal wall and BN Minimize LND in area of hypogastric n. plexus Post cystectomy innervation contributes to continence Tonic neural discharge to EUS at all times increases with bladder filling

Neobladder: How I do it Technical points:  Female Cystectomy

Neobladder: How I do it Technical points:  Female Cystectomy

Neobladder: How I do it Technical Points:  Why the Hautmann ? Good functional outcomes Large capacity Simple to construct No foreign bodies/nipples Easy to adapt to anatomical variations Easy to revise if problems arise

Neobladder: How I do it Technical Points:  Modified Hautmann Urethral Tubularization (Hautmann) Anastomotic tension no longer a problem Facilitates future urethrectomy if necessary Contributes to continence ?

Neobladder: How I do it Technical Points:  Modified Hautmann Chimney Modification (Theodorescu) Facilitates ureteroileal anastomosis Easily adaptable for short ureters (L or R) Permits easy revision/resection of anastomosis