Speaker 1Okay, in this class, we're going to begin our discussion of continent urinary diversions. We're going to start with orthotopic neobladder. That's the most common continent urinary diversion done at this point in time. So we're going to talk about what is meant by the term orthotopic neobladder. We're going to talk about the indications, contraindications, and criteria for orthotopic neobladder construction. We're going to talk about pre-op education and then post-op considerations and education for the patient undergoing orthotopic neobladder. So first of all, let's just look at that term, orthotopic neobladder. So orthotopic means that the new organ is placed in the same position as the original organ. So it means that the newly constructed reservoir will be placed in the pelvis right where the bladder originally was located. And neobladder means exactly what it says. It's not the same as the bladder. It's a newly constructed reservoir, it's designed to essentially take the place of the bladder. So when you look at orthotopic neobladder, what they do is they construct a reservoir from the small bowel. So they line up loops of small bowel, they open those loops of bowel so that they eliminate contractility. They reconfigure those loops of bowel to create a reservoir. And there's more than one approach. So the two most common approaches. Are the Studer approach and the Haltmann approach. And the big difference is just the shape of the reservoir. So far as we know, there's really no difference long term in terms of outcomes. No difference in terms of management, but Studer ends up being more U-shaped and Haltmann ends up being more W-shaped like you see at the bottom right. So they've created the reservoir. You have to connect it to the urethra, so they create a little buttonhole opening in the distal portion of the reservoir and they connect that to the urethra. You'll see that even more clearly in some later slides. So what is going to maintain continence? We've removed the bladder. We've removed the bladder neck. We've created a reservoir. We've made a little hole in the distal. The distal portion of the reservoir connected it to the urethra. Continence is going to be dependent on the external sphincter which is located just distal to the prostate in men and about halfway down the urethra in women. So it's critical for that external sphincter to be intact, innervated and functioning normally. That is your primary continence. Now continence is supported by the fact that the reservoir itself is a contractile, so it's a passive reservoir. It's not contracting and trying to force urine out the urethra. So that helps support continence. Now the major benefit of an orthotopic neobladder as compared to standard cystectomy and ileal conduit. They don't have a stoma. They don't wear a pouch. They don't have issues related to pouch leakage, peristomal skin complications. But there are some potential issues. So a neobladder is not the same as your original bladder. First of all, it's a contractile. So the patient has to relearn to void and incomplete emptying and some degree of retention is a potential complication. Some patients may end up needing to self-catheterize. Also, instead of having the internal sphincter, which is located at the bladder neck and the external sphincter, now you only have the external sphincter and an acontractile reservoir. So leakage is a potential issue as well. Who is a candidate? Well, any patient with a sphincter. Any patient who requires removal of the bladder is typically a candidate for both an ileal conduit or a neobladder. So long as the external sphincter is intact and innervated and they have no issues with urinary incontinence. If they have baseline issues with urinary incontinence, neobladder is not an option. Also, the urethra. The urethra itself has to be free of malignancy. If urethrectomy is required, that would involve removal of the external sphincter. That would eliminate your continence mechanism. So if urethrectomy is required, the patient is not a candidate for a neobladder. Obviously the patient has to be cognitively intact. They have to be able and willing to do self-catheterization if necessary. If they have problems with incomplete emptying. And finally, if you have a patient who is obese or morbidly obese, actually neobladder is a better option than an ileal conduit because, as we have discussed, obesity creates a lot of issues with stoma construction. And obese patients are much more likely to have retracted stomas that are difficult to pouch. There are contraindications as well. So, first of all, if the patient has any degree of hepatic dysfunction or renal failure. And when they talk about renal failure, they usually consider a creatinine of 1.7 as kind of the cutoff. If your creatinine is below 1.7, your renal function is adequate, if it's 1.7 or above, then you're going to think twice before offering neobladder to that patient. And you think, well, what does liver function have to do with the neobladder? Well, here's the issue. So, you've created this reservoir out of loops of bowel. Urine is going to sit in that reservoir for prolonged periods of time. So, there is the risk that you'll get reabsorption of electrolytes from the urine and secretion of electrolytes from the liver. And if you have a patient who is obese or morbidly obese, then you're going to think twice before offering neobladder to that patient. So, there is the risk that you'll get reabsorption of electrolytes from the urine and secretion of electrolytes into the urine. So, it's fairly common to have some metabolic issues. And as you know, the liver and the kidneys help to compensate for any metabolic abnormalities, help to maintain activity. Acid-base balance and fluid-electrolyte balance. So, if your compensatory organs are not doing well, this is not a good choice. Don't add to their workload. So, liver failure is a contraindication. Renal failure is a contraindication. Pelvic radiation is a relative contraindication because you know tissues that have been irradiated have compromised perfusion. That compromises healing. So, in general, not a good choice for people who have had pelvic radiation. Definitely not a good choice for patients who have undergone previous small bowel resection and they have limited length of small bowel or people who have active small bowel disease like Crohn's because where are we going to use for the reservoir? Small intestine. And as we've already said, any patient who has urinary incontinence. Any patient who has urinary incontinence at baseline. Any patient who requires urethrectomy. So, we're working with patients preoperatively, postoperatively. What do we need to make sure they understand preoperatively? First of all, we want them to understand that this is not an even swap. We're not taking out their diseased bladder but giving them an equally good replacement bladder. There are differences. There are differences in the neobladder and in their native bladder. The neobladder is acontractile, so they're going to have to relearn how to urinate. They have to understand that if they have difficulty effectively emptying urine from the neobladder, they will have to do catheterization. And that there are some patients who have undergone this procedure who have to catheterize themselves every day. That's not typical, but it can occur. In some centers, patients are routinely taught self-catheterization during the preop period to make absolutely sure that, number one, they can perform the procedure, number two, they're comfortable with the procedure, and number three, that they're acutely aware of that they may need to do this postoperatively they have to understand the importance of voiding on schedule you don't want the reservoir to overdistend so they've got to void on schedule they have to relearn voiding and they also have to be aware that instead of having an internal sphincter and an external sphincter now they just have the external sphincter so they're higher risk for leakage especially at night when they're asleep and the level of muscle tone and resistance diminishes they have to understand that they might need absorptive products at night most people do not need it during the day but we can't guarantee that so before they say yes I want that orthotopic neo bladder that sounds perfect take out the disease bladder just replace it now we're not just replacing it big differences potential problems incomplete emptying you may need to catheterize routinely and you may have problems with leakage so we need to be sure that they're very clear on that now what studies have shown is if we provide patients with a clear understanding of what's involved with an ileal conduit you have a stoma you wear a pouch you have to learn how to manage that pouch how to change that pouch you could potentially have problems with pouch leakage versus a continent urostomy where you have an internal reservoir and you pass a catheter through an abdominal wall stoma to empty the reservoir and you have to do that catheterization multiple times a day forever versus the orthotopic neo bladder where you have no stoma no pouch you have an internal reservoir connected to the urethra but you have the potential for incomplete emptying you may potentially need to catheterize yourself and there's the potential for leakage if they have clear understanding of the three options the three alternatives and the potential issues with each and if they make their own decision then the vast majority are pleased with their decision long-term most patients say I would make the same decision I'm glad I picked this I've had patients who did exactly the same research they said I went online I talked to other people I talked to my surgeon talked to ostomy nurses and they come to very different decisions so one patient said I'm gonna go with the ileal conduit because that's the most established safest option and I can handle wearing a pouch and then I've had other people who say no I really don't want to wear a pouch I'm worried about leakage blah blah I'm gonna go with the orthotopic neo bladder I had one patient who said he woke up at night worried about maybe having to catheterize himself and that that was his biggest concern he's like I kind of want the neo bladder but I don't know the idea of catheterizing myself it literally makes me sick to my stomach we're like you don't want to have this done we need to look at it from the outside we need to look at the continent, urostomy, or an ileal conduit he's like I don't want to put a catheter anywhere he needed an ileal conduit so our role is not to make their decision our role is provide them with information answer their questions listen to what they're saying to us and feed it back to them so that they make the best decision for themselves we should do stoma site marking preoperatively because sometimes they go to surgery with plans for an orthotopic neo bladder and at surgery they find that there is malignant extension into the urethra that urethrectomy is required neo bladder is not an option and an ileal conduit is required so now let's talk about post-operative management it's usually shared by the urology team clinic nurses hospital nurses and ostomy nurses so think about what's happened we have created a reservoir so of course we have long suture lines or stable staple lines and we've connected that reservoir to the urethra we've made a little buttonhole opening look mid-screen you see your little buttonhole opening connected to the urethra and remember the urethra is a narrow channel about a quarter inch so we will that reservoir to heal normally before it distends we have to support the anastomosis between the reservoir and the urethra so that we don't get stenosis and obstruction and retention and also think about your ureters your ureters have been disconnected from the original bladder and connected to the neo bladder so we need to protect the ureterole and testicle anastomosis until those anastomotic lines heal and the edema has resolved so we want to keep the neo bladder decompressed we want to prevent stenosis at the reservoir urethral anastomosis and we want to protect the point at which the ureters are anastomose to the reservoir and how do we do that tubes tubes and more tubes so I tell patients when I talk to them preoperatively you're going to have a lot of tubes and before you go home we will make sure you know how to manage any tube that is going to go home with you and then I provide them the level of detail in terms of information that they want so you let them know there will be a lot of tubes if they have questions you follow up some of my patients are like well tell me about the tubes how many tubes will I have where will they be going other patients are like I'll deal with that post-op so you will have you will see ureteral stents now sometimes they're internalized and sometimes they're externalized but always there will be stents to protect the ureteral intestinal anastomosis to maintain patency of the anastomotic line now sometimes the surgeon puts the stents in from the renal pelvis through the ureter into the neo bladder but does not bring them out and in that case the urologist will go back two to three weeks post-op he will do an endoscopy of the reservoir and he will remove the stents at that point in many settings the stents are externalized in our setting the stents are externalized so they literally make a little stab wound through the reservoir and through the abdominal wall and they bring the end of the stents out through the abdominal wall and we pouch them they remain in place typically two to three weeks so we have to teach them to pouch when they go home and then in the clinic the urologist removes the stents so they may be internalized or externalized you will always have stents and the only issue is do you have to do anything does the patient have to do anything to care for the stents everyone will have a reservoir catheter so a reservoir catheter is actually placed through the reservoir through the abdominal wall and to a drainage bag sometimes it's called a suprapubic catheter because it typically exits through the suprapubic area but its purpose is to keep the reservoir decompressed until healing is complete and typically it's irrigated at intervals just to maintain patency for most patients it's the last catheter to be removed patients typically also have a urethral catheter because remember they made a little buttonhole opening at the distal end of the reservoir they connected it to the urethra it's a very narrow circular anastomosis and very prone to stricture so it's critically important to place that urethral catheter into the neobladder to support that anastomotic line to maintain patency to prevent stricture formation and typically it is removed about two to three weeks post-op, typically it is irrigated PRN to eliminate mucus and maintain patency. So stents, reservoir catheter, urethral catheter, all very common. And then there will also be surgical drains. So now the patient's ready to go home. What do they need to know when they're getting ready to go home? We have to look at what catheters, what tubes are going home with them, and what do they need to do to manage those tubes. So they definitely need to know how to empty drainage bags. So they need to know wash your hands, clean the spout, drain the spout, clean it again, close it. Usually we teach them to irrigate the reservoir catheter and to irrigate the reservoir catheter. So they need to know how to irrigate the reservoir catheter and possibly the urethral catheter with saline to maintain patency. So if the surgeon does want irrigation continued post-discharge, we have to make sure that the patient or the caregiver understands the importance of the irrigation procedure and that we've checked them off on the procedure itself. And then if the stents have been externalized and we're pouching them, we have to make sure that the patient and or caregiver can change that pouch. They'll only have to do a couple of pouch changes most of the time, but they have to know how to do that. So a common question from patients is when do they start taking these out? What comes out first? What's the last one to come out? So they're going to base it on the intent of the specific tube. And the time frame for anastomotic healing. In general, tubes are removed somewhere between two and four weeks post-operatively depending on patient status, expected time frame to healing, surgeon preference. So urethral stents typically removed either during the first or second post-op visit back to the clinic. So usually about two to three weeks post-operatively. The urethral catheter typically removed about two to three weeks post-operatively. Some surgeons might leave it in for four. The reservoir catheter is typically the last catheter removed usually at about three to four weeks. So usually the stents and the urethral catheter come out first. Then we teach the patient voiding. We have them record voided volumes. And many times, we'll have them drain the bladder using the reservoir catheter after they void so that we can see what their post-void residual is running. Long-term. Long-term, our goals are to teach the patient effective voiding. We want to increase reservoir capacity. And we want to minimize or eliminate any leakage. So when the patient comes back to clinic, stents are removed, urethral catheter is removed, we're ready to teach the patient how to void. So at this point, the reservoir catheter is usually still intact. But we can cap it or plug it. So it becomes a just-in-case catheter. So let's say the stents are out, urethral catheter is out, and I've plugged the reservoir catheter. So now the reservoir is going to begin filling with urine. And we're going to put the patient on a voiding schedule. Typically, we start out with every two hours. And every week, we typically advance the voiding interval by about an hour. We can give the patient a chart. So we're going to say, okay, now we want you to write down every time you urinate, we want you to urinate into a urinal or into the hat, and we want you to write down how much you get. Many times, we will tell the patient, okay, at 8:00, you're going to sit or stand to urinate. You're going to measure the amount of urine you got. Then you're going to dump the urinal, dump the hat, open up your reservoir catheter and see how much urine is left in the neobladder. So their chart should tell you the time, the amount voided, and their post-void residual. And what we hope to see is that over the first few weeks, that voided volumes increase and post-void residual decreases. That means that they're learning how to effectively empty the bladder. For patients who have problems emptying effectively, remember, we have to teach them how to catheterize and they have to be willing to do this. So again, it's going to depend heavily on that surgeon's protocols. At what point does he want the patient to self-catheterize? But a lot of times, we're involved in reinforcing that teaching with the patient, making sure they understand what their management protocol looks like at this point. How often should you be urinating? What techniques do you use to facilitate bladder emptying? The critical importance of measuring post-void residual and then indications for catheterization and a reminder of the technique. Okay. We need to teach patients pelvic muscle exercises so that they can begin to strengthen that external sphincter and reduce the risk of leakage. And they need to know what absorptive products are available to them until leakage is eliminated. So let's talk about some of the specifics. So we've told the patient they're going to have to relearn how to void, how to urinate. Well, specifically, what does that involve? In the past, and for all of you, when you have to void, your whole goal is to make it to the bathroom and then you have to do is essentially give your bladder permission, open the sphincter, the bladder contracts, you empty. You don't really think about it. But the patient with the neobladder has an A contractile reservoir. So what they have to learn to do is to voluntarily relax the sphincter and then use the Valsalva maneuver to increase abdominal pressure to force urine out. So you teach them to bear down to empty the bladder. Some patients benefit from manual compression of the lower abdomen to further increase pressure against the reservoir to facilitate empty. A lot of times I'll tell men, you know, you're recovering from surgery, you're relearning how to void. You might come out better at first if you sit to void because you're still weak. But if you sit to void, you're not concentrating on remaining upright. And you can focus all of your attention on relax the pelvic floor muscles, bear down with your belly muscles like you're having a bowel movement, use abdominal compression. And let's see how effectively you can empty. And remember, you're going to get better and better at this. So don't be too discouraged if right at first, you're not emptying completely at all. It's going to get better. We want them to know their schedule. We want them to know how critically important it is for them to write down their voided volumes. We want them to know to open the reservoir catheter if that's part of their protocol and to document the amount of residual urine. Also, we need to tell them we have you urinating on schedule. But also, you've got to pay attention to when you feel full. Now that feeling of fullness is not going to be the same as when you had your regular bladder. But pretty quickly, you're going to start to recognize when your reservoir is full. And when your reservoir is full, you need to go urinate. So you're going to urinate on schedule and anytime you feel full. And when your reservoir is full, you need to go urinate on schedule and anytime you feel full. But men and women can use pelvic muscle exercises to further strengthen the pelvic floor muscle sling and the external sphincter. So if you look mid-screen you can see the pelvic muscle sling for both men and women. So you can see it hits just below the prostate in men and at mid urethra in women. So what we tell patients is okay contract your pelvic floor. Think about holding in gas, holding in stool. So contract the pelvic floor like you're trying to hold in gas, hold in stool. Contract it as hard as you can. Hold as long as you can and then relax for 10 seconds. And we want you to do three sets a day, 15 reps per set. So just like lifting weights for your pelvic floor. We want to strengthen the pelvic floor improve your ability to maintain urethral closure and to prevent leakage until we get there. And for as long as you're experiencing any degree of leakage you are going to need to use absorptive products. So go to the drug store, go to the grocery store and look at what's available to you. So for women there are pads that strip to their underwear with different levels of absorbency. Poise pads are one brand that's commonly used. But it doesn't matter the brand name. It just matters that they get a pad with the right level of absorption. For men they're looking for male guards. They strip to the underwear. They're cup shaped so that they fit right around the penis. They're perfect. And again you can get different levels of absorption. So you won't have to worry too much about that. You just want them to know what they're looking for. And you want them to understand that this is perfectly normal at this point in time in recovery. We want them to maintain adequate fluid intake at least two liters a day. And they really need medic alert to alert anyone that they have an orthotopic neoblatter. So that they're aware of that if the patient's in an accident they end up in the emergency department. They're passing a catheter. They need to be aware that they're dealing with a neoblatter and not the native bladder. So in summary orthotopic neoblatter is an alternative to cystectomy with ileal conduit. It is being used fairly widely in medical centers across the world. It involves construction of an acontractile reservoir. It's constructed from loops of small bowel. It's connected to the urethra. And you end up with your external sphincter as your primary continence mechanism. Voiding is going to require the patient to relax the pelvic floor. Use the valsalva maneuver. Possibly manual compression over the lower abdomen. Continence is dependent on the acontractile nature of the reservoir. And an intact, innervated, and strong external sphincter. So one element of patient teaching is pelvic muscle exercises. Long-term the most common issues are incomplete emptying and the need to do self-catheterization. And leakage especially at night or when someone's asleep. And the need to use absorptive products. Okay that's it for orthotopic neoblatter. Thank you.
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