Lesson 33: Orthotopic Neobladder

Question 1

Orthotopic Neobladder - Definition

Answer 1

• Creation of urinary reservoir connected to urethra “neobladder”
• Constructed from detubularized loops of ileum

2 common type
- Studer Pouch - u-shaped reservoir
- Hautmann Pouch - w-shaped reservoir

Buttonhole opening created in distal pouch + connected to
urethra
- Continence via external urethral sphincter

Question 2

Orthotopic Neobladder - Pros + Cons

Answer 2

Pros
- No stoma
- No external pouch
- No pouching issues

Cons
- Incomplete emptying
- Urinary retention
- Urinary leakage

Question 3

Criteria for Neobladder

Answer 3

• patient who requires cystectomy d/t bladder cancer
• External sphincter must be intact and innervated
• Urethra free of malignancy
• Patient is cognitively intact + able to perform intermittent catheterization PRN

Question 4

Neobladder Contraindications

Answer 4

• urinary incontinence
• Urethral malignancy
• Hepatic or renal dysfunction
  — Need creatinine > 1.7
  — Can cause metabolic abnormalities
  — D/t constant exposure of urine to bowel mucosa
• Pelvic radiation
• Risk of compromised healing + anastomotic breakdown
• Small bowel disease or limited small bowel length

Question 5

Patient Education

Answer 5

• understanding of procedure
• Potential need for self-catheterization
• Importance of voiding on schedule
• Potential for leakage + need for absorbent products
• Critical for informed decision making between
  — Ileal conduit
  — Neobladder
  — Continent urostomy
• Stoma site marking in case of ileal conduit

Question 6

Goals of Healing

Answer 6

Keep neobladder decompressed until suture line is well-healed

Prevent stenosis of suture line between neobladder and urethra

Maintain patency of urethra-ileal anastomosis

Question 7

Tube Management - Urethral Stents

Answer 7

• May terminate in neobladder
• Can be externalizer through stab wound on abdomen
• Are pouched
• Removed 2-3 weeks post-op

Question 8

Tube Management - Reservoir Catheter

Answer 8

• Brought out through stab wound in abdomen
• Provides drainage for reservoir
• Irrigated routinely + PRN to remove mucous
• Removed 3-4 weeks post-op

Question 9

Tube Management - Urethral Catheter

Answer 9

• Supports anastomosis of reservoir to urethra
• May be irrigated routinely + PRN to remove mucous
• Removed 2-3 weeks post-op

Question 10

Long-Term Patient Expectations

Answer 10

Goals
- emptying of neobladder
- increase reservoir capacity
- minimize/manage urinary leakage

Strategies
- Scheduled voiding Q2H
— Pelvic muscle relaxation
— Valsalva
— Abdo wall compression
- Documentation of voided volumes + post-void residuals
- Intermittent self-catheterization PRN
- Irrigation PRN
- Pelvic muscle exercises to strengthen sphincters
— Contract as if holding gas/stool
— Hold as long as possible
— Relax
— Repeat 3 sets per day, 15 reps per set
- Absorptive products + skin care
- Need to wear Medical Alert ID