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Neobladder Urinary Diversion
Neobladder Urinary Diversion
(Female patient pictured above-left, male patient pictured above-right)

For patients with invasive bladder cancer, surgical removal of the bladder, called a cystectomy, provides the best chance for a long-term cure. In the past, following bladder removal all patients were required to wear a bag on the outside of their body to collect urine, a permanent condition that necessitated significant lifestyle adjustments. Today, many of these patients qualify for what is known as a neobladder -- an internal urine-storing pouch that is attached to the urethra, which allows patients to regain control of urination and to void much as they would with their natural bladders. Thanks to recent advances in the procedure, the majority of patients undergoing bladder removal surgery at Memorial Sloan-Kettering Cancer Center are able to receive neobladders.

Invasive Bladder Cancer and Cystectomy

Of the estimated 61,000 Americans who will be diagnosed with bladder cancer this year, nearly 90 percent will have what is known as transitional cell carcinoma (TCC). While about 75 percent of TCC cases are confined to the lining of the bladder, the remaining 25 percent of cases are invasive, meaning that the cancer has penetrated the bladder lining, invading the muscular wall of the bladder and possibly other nearby organs. For these patients, a surgical procedure known as a cystectomy is performed to remove the bladder along with surrounding affected structures. (For men, this procedure also entails the removal of the prostate, seminal vesicles, lymph nodes, and part of the vas deferentia. For women, surgeons also remove the uterus, fallopian tubes, ovaries, lymph nodes, and possibly part of the vagina.) Once the bladder has been removed, surgeons must create a new way for the body to store and eliminate urine.

Urine is produced in the body's two kidneys, both of which are connected to tubes called ureters. Ureters carry urine to the bladder, where urine is stored until it is expelled through a tube called the urethra. In a traditional cystectomy (also called an ileal conduit diversion), the surgeon performs what is known as a cutaneous diversion, a procedure in which a conduit, or passageway, for urine is created using a segment of the patient's small intestine. This conduit transfers urine directly from the kidneys and ureters to a surgically created opening in the abdomen, called a stoma, which funnels the urine into a collection bag worn on the abdomen.

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Dr. Bernard Bochner
Dr. Bochner explains the neobladder urinary diversion procedure.
Runtime: 1 minute 22 seconds.

Neobladder Urinary Diversion

In the neobladder procedure, an internal pouch is formed using a section of small intestine and the new "neobladder" is attached to both the ureters and the urethra, effectively serving as a substitute bladder that allows patients to urinate using the urethra. After surgery, patients with neobladders are instructed to follow a course of exercises, which helps strengthen pelvic muscles, in order to regain urinary control, or continence. Some incontinence will remain until the neobladder pouch is adequately stretched and the pelvic muscles are strengthened. With regular exercise, significant improvement in urinary control usually begins about two months following surgery. Nighttime control may take longer.

"Our surgical techniques have progressed to a point where the vast majority of men and women receiving neobladder diversions will have near-normal urinary control that allows for an excellent quality of life after surgery," says Bernard Bochner, a urologic surgeon at Memorial Sloan-Kettering.

Treatment Hesitation and Surgical Skill

In the past, Dr. Bochner notes, concerns over the need to wear a urine collection bag caused some invasive bladder cancer patients to put off the procedure. The resulting delay in treatment may have affected their long-term outcomes. Recent research has suggested that urinary-function-preserving neobladder surgery encourages individuals to receive treatment sooner, when the likelihood of a positive treatment outcome is greatest.

Dr. Bochner cautions that the neobladder technique does require greater surgical skill than the traditional ileal conduit diversion. Qualified patients are advised to seek out a center that has successfully performed a large number of these procedures. Of the more than 200 radical cystectomies with urinary tract reconstruction procedures that are performed each year at Memorial Sloan-Kettering, more than half will include neobladder reconstruction.

Nerve-Sparing Technique Preserves Sexual Function for Men

While men account for three out of every four cases of bladder cancer in the US, the traditional cystectomy often includes the removal of the nerve bundle that controls erections. In many cases, cystectomy with a neobladder urinary diversion allows surgeons to spare this nerve bundle, thereby preserving a man's sexual function.

"Removing all the cancer remains the primary goal for bladder cancer surgery," Dr. Bochner explains. "But in male patients who qualify for nerve-sparing and urethra-sparing surgery, the majority of these men will benefit and achieve spontaneous erections after surgery."

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Last Updated: Sep. 17, 2007
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