[15 years experience with the ileal neobladder. What have we learned?].

During the past 15 years, orthotopic bladder reconstruction has evolved from experimental surgery over "standard of care at larger medical centers" to become the preferred method of urinary diversion in both sexes. The paradigm for choosing a urinary diversion has changed substantially over that time. In 2001, all cystectomy patients are candidates for a neobladder, and we should identify those patients in whom orthotopic reconstruction may be less ideal, noting that the percentage of patients receiving a neobladder today averages 60 to 70 percent. Relative contraindications and comorbidity now play a smaller role in choosing the neobladder option. Patient selection criteria include both patient factors and cancer factors. The primary patient factor being the patient's desire for a neobladder. The psychologically damaging stigma to the patient who enters surgery expecting a neobladder but awakens with a stoma now plays an increasing role. Nevertheless, there are patients who are better served with a conduit. Among that are patients whose main motivation is to "get out of the hospital as soon as possible", and patients who will be happy to resume a normal, relatively sedentary life and who have no concerns about body image. Two important criteria that must be maintained when contemplating a neobladder procedure--the urethral sphincter must remain intact and the cancer operation must not be compromised. However, increasing experience has forced less restrictiveness as far as tumor stage is concerned. A recent study of 435 bladder cancer patients who had bladder replacements after cystectomy, experienced a local recurrence rate of 10 percent. Interference of the local recurrence with the neobladder occurred in just 11 patients--infiltration in six, and obstruction in five. Survival was limited despite multimodality therapy. The option of a neobladder reduced the physician and patient reluctance to perform cystectomy early in the disease process, thereby increasing the survival rate, and patients can anticipate normal neobladder function until time of death. It can be concluded that a neobladder for locally advanced cancer and positive nodes is no more problematic than a conduit. The structural and ultrastructural changes which occur in neobladder mucosa are biphasic. The early phase is inflammatory, showing an infiltration of the lamina propria and a reduction in microvilli. After one year the late regressive phase starts, ending up in a flat mucosa and a stratified epithelium. The structure and response of the implanted ileum change to a detrusor-type: response. The structural and ultrastructural changes an ileal mucosa lead to a primitive surface and glandular epithelium similar to urothelium. This transformation of the ileal mucosa minimizes the risk of metabolic complications. We conclude that mother nature engineers a new bladder almost as good as the one given by God initially. The risk of obstruction of non refluxing techniques is at least twice that following a direct anastomosis. There is no longer a justification of any antireflux mechanism. Ileum seems to be clearly superial to colon when continence rates, metabolic safety and surgeons's issues are considered.