ILEAL NEOBLADDER 427

No more than 1 pad a day, d a m p More than 1 p a d a day, we t or soaked

Completely dry without need for protection Completely dry , protection for safety Completely dry wi th 2 voids a night Completely dry wi th 3 voids a night No more than 1 pad a night, damp once or twice a week N o more than 1 pad a night, d a m p More than 1 p a d a night, we t or soaked

Nighttime:

REFERENCES

1. Studer, U. E., Hautmann, R. E., Hohenfellner, M., Mills, R. D., Okada, Y., Rowland, R. G., Tobisu, K. and Tsukamoto, T.: Indications for continent diversion following cystectomy and factors affecting long term results. Presented a t Fifth Inter- national Consensus Meeting on Bladder Cancer, Tokyo, Ja- pan, 1997.

2. Hautmann, R. E., Egghart, G., Frohneberg, D. and Miller, K.: The ileal neobladder. J . Urol., 139 39, 1988.

3. Wenderoth, U. K., Bachor, R., Egghart, G., Frohneberg, D., Miller, K. and Hautmann, R. E.: The ileal neobladder: experi- ence and results of more than 100 consecutive cases. J . Urol., 143 492, 1990.

4. Skinner, D. G., Studer, U. E., Aso, 0. K., Hautmann, R. E., Koontz, W., Okada, V., Rowland, R. G. and Velthoven, R. F.: Which patients are suitable for continent diversion or bladder substitution following cystectomy or other definitive local treatment? Int. J . Urol., suppl., 2: 105, 1995.

5. Thiiroff, J . W., Mattiasson, A,, Andersen, J . T., Hedlund, H., Hinman, F., Jr., Hohenfellner, M., Mansson, W., Mundy, A. R., Rowland, R. G. and Steven, K.: The standardization of termi- nology and assessment of functional characteristics of intesti- nal urinary reservoirs. Brit. J . Urol., 7 8 516, 1996.

6. Skinner, D. G. and Lieskovsky, G.: Technique of radical cystec- tomy. In: Diagnosis and Management of Genitourinary Can- cer. Philadelphia: W. B. Saunders Co., chapt. 42, pp. 607-621, 1988.

7. Hautmann, R. E., Miller, K., Steiner, U. and Wenderoth, U.: The ileal neobladder: 6 years of experience with more than 200 patients. J. Urol., 150 40, 1993.

8. Myers, R. P.: Improving the exposure of the prostate in radical retropubic prostatectomy: longitudinal bunching of the deep venous plexus. J . Urol., 142: 1282, 1989.

9. Walsh, P. C., Quinlan, D. M., Morton, R. A. and Steiner, M. S.: Radical retropubic prostatectomy. Improved anastomosis and urinary continence. Urol. Clin. N. Amer., 17: 679, 1990.

10. Le Duc, A., Camay, M. and Teillac, P.: An original antireflux ureteroileal implantation technique: long-term followup. J. Urol., 137: 1156, 1987.

11. Lippert, M. C. and Theodorescu, D.: The Hautmann neobladder with a chimney: a versatile modification. J. Urol., 158: 1510, 1997.

12. Matsui, U., Topoll, B., Miller, K. and Hautmann, R. E.: Metabolic long-term follow-up of the ileal neobladder. Eur. Urol., 24: 197, 1993.

13. Bachor, R., Frohneberg, D., Miller, K., Egghart, G. and Hautmann, R. E.: Continence after total bladder replacement: urodynamic analysis of the ileal neobladder. Brit. J. Urol., 65: 462, 1990.

14. Elmajian, D. A,, Stein, J. P., Esrig, D., Freemann, J . A., Skinner, E. C., Boyd, S. D., Lieskovsky, G. and Skinner, D. G.: The Kock ileal neobladder: updated experiences in 295 male patients. J . Urol., 156 920, 1996.

15. Studer, U. E. and Zingg, E. J.: Ileal orthotopic bladder substi- tutes. What have we learned from 12 years' experience with 200 patients. Urol. Clin. N. Amer., 2 4 781, 1997.

16. Stampfer, D. S., McDougal, W. S. and McGovern, F. J.: Metabolic and nutritional complications. Urol. Clin. N. Amer.. 24: 750, 1997.

17. Hautmann, R. E. and Paiss, Th.: Does the option of the ileal neobladder stimulate patient and physician decision toward earlier cystectomy? J . Urol., 159 1845, 1998.

18. Martins, F. E., Bennett, C. J . and Skinner, D. G.: Options in replacement cystoplasty following radical cystectomy: high hopes or successful reality. J. Urol., 153: 1363, 1995.

Incontinent

Continent

Unsatisfactory Good Good

Functionally continent Satisfactory

Socially continent Satisfactory

Incontinent Unsatisfactory

19. Rowland, R. G.: Complications of continent cutaneous reservoirs and neobladders-series using contemporary techniques. AUA Update Series, vol. X I V , lesson 25, pp. 202, 1995.

EDITORIAL COMMENT

Techniques of orthotopic bladder replacement and continent urinary diversion are well established. A followup of more than 12 years is available for most larger series and complications that might occur have been reported. Nevertheless, studies of series with long-term followup are also important to observe possible changes in complication rates with time.

This series is one of the largest reported concerning orthotopic ileal bladder replacement. A major drawback of all series of patients with bladder cancer is a dropout rate of about a third during followup due to tumor progression. Thus, the complication rate can only be determined with regard to those who survive. The early complication rate of 39.1% in the present series is high. However, most of the complications (33.6%) were not related to the neobladder in contrast to the 15.4% of complications related to neobladder (several patients had more than 1 complication). Surprisingly, the most common com- plication was prolonged ileus, which was already reported previously from the same center (reference 7 in article).' Interestingly, the prolonged ileus seems to occur more often with an ileal neobladder compared to continent urinary diversion,z except for the data re- ported by Kock. The reasons remain unclear. The 32% late compli- cation rate is in accordance with the literature for other techniques of urinary diversion.

Whereas reported daytime continence is good in 83.7% of the patients, only two-thirds (66.3%) have good nighttime continence. Some of the patients required 5 years to become completely dry. The authors argue that the preoperative continence rate was only 88.9%. However, patients with continent urinary diversion have continence rates greater than 90% day and night independent of the preopera- tive continence status. Even after 5 years 15% of the patients with an ileal neobladder must awake more than 2 times during the night to stay completely dry. However, this series confirms that orthotopic bladder substitution has become a standard technique after cys- toprostatectomy at the expense of somewhat higher complication rates compared to incontinent conduit diversion.

Joachim W. Thuroff Department of Urology Johanes-Gutenberg- University Medical School Mainz, Germany

1. Flohr, P., Hefty, R., Paiss, T. and Hautmann, R.: The ileal neobladder-updated experience with 306 patients. World J . Urol., 14: 22, 1996.

2. Rowland, R. G.: Complications of continent cutaneous reservoirs and neobladders-series using contemporary techniques. AUA Update Series, XIV: 25, 1995.

REPLY BY AUTHORS

The most dramatic quality of life change for patients undergoing cystectomy is the need for urinary diversion. In the past fear of the bag and the stoma led many patients as well as urologists to delay or avoid definitive treatment. We have witnessed the development and refinement of various types of continent urinary diversion. Initially reservoirs drained through cutaneous stomas. These pouches are difficult to construct and require a significant learning curve to achieve reasonable results. Patient motivation and dexterity are required to master catheterization of the stoma. Late complications are common with these systems, including difficult catheterization, stone formation in the reservoir, incontinence and the risk of chronic