mCancerPartner sat down recently with Cheryl Lee, M.D., a surgeon and associate professor of urology to discuss options for cancer patients who have their bladder removed, including the neobladder. Dr. Lee’s research focuses on improving quality of life and surgical outcomes for bladder cancer patients. She is also active with the Bladder Cancer Advocacy Network, where she co-chairs the Survivorship Committee and serves on its Bladder Cancer Research Network .
mCancerPartner: What is a neobladder, and how does it differ from the ileal conduit and Indiana pouch?
Dr. Lee: The bladder’s main function is to store urine, so when we remove it, which is sometimes necessary for bladder cancer patients, we need another way to store urine or divert it out of the body. There are several ways to do it. Historically, the ileal conduit is the most common, where we take 15-20 centimeters (about 6-8 inches) of the ileum, part of the small intestine, and create a small tube so urine can leave the body. We attach the ureters, which drain the kidneys, to the base of the conduit and bring the tube through the belly wall. Urine then evacuates into an external appliance or “bag,” as people commonly call it.
Another diversion is called the Indiana pouch, or the right colon pouch. Instead of using the small intestine, it is made from the right colon, which we remove from the intestinal stream to become an internal pouch for storing urine. We also take 10-15 centimeters (about 4-6 inches) of the small intestine to form a limb that will connect the pouch to the outer abdominal wall. The patient passes a catheter through the opening in the abdomen to manually drain the pouch.
Another type of urinary diversion is the neobladder, or “new” bladder. It isn’t the same as the one you were born with, but it does permit a natural pattern of voiding. We use a section of the small intestine to create a pouch or bladder with enough capacity to hold urine. It is placed where the old bladder used to be, with all the same connections to receive urine from the kidneys and pass it out of the body through the urethra. This type of diversion uses 3-4 times the amount of small intestine used for the ileal conduit.
In all of these diversions, there is an increased risk of infection over one’s native bladder. The more complicated the diversion, the higher the risk of infection.
mCancerPartner: Why is the neobladder an attractive option?
Dr. Lee: The neobladder allows the patient to urinate in a more natural way. This concept of having everything inside the body with no need for an external appliance or pouch is attractive to many patients and gives them a sense of normal voiding patterns. However, since the neobladder is made from tissues that are different from one’s native bladder, it has some behaviors that the original bladder didn’t have.
For example, the muscle system in the wall of the small intestine is different than a native bladder. So although it holds and stores urine and you can empty it, sometimes the neobladder needs more help to void. You may have to push pressure onto your belly, bear down, or change positions to increase pressure in your belly to help drain the neobladder. Some patients may not be able to void all the urine in the neobladder, making it necessary to use a catheter, pass it though the urethra and into the neobladder to drain it.
Another characteristic of the small intestine is to produce mucus, so the neobladder does this, too. Patients should keep hydrated to make sure mucous stays thin and empties with the urine. The neobladder also wants to absorb some of the waste materials found in urine, so patients have periodic blood tests to make sure the salts in the body stay within the normal range.
mCancerPartner: Who is the ideal candidate for a neobladder?
Dr. Lee: When I think of the ideal candidate, I think of someone who has had a good discussion with a urologic surgeon about:
- what the neobladder is
- long term impact in terms of metabolic function in the body
- physical ability and willingness to catheterize if needed
- willingness to work hard to gain urine control
- recognition that urine control at night may be a challenge
It’s equally important for the patient to have at least one other conversation with someone who already has a neobladder.
mCancerPartner: How does a patient decide among these three urinary diversions?
Dr. Lee: Often when I talk to patients, they want to know which is the best diversion to have. The right colon pouch is the most complicated, the ileal conduit is the most straightforward, and the neobladder is in the middle, but there’s no right answer. I let them know the choice is a personal one, based on factors like expectations, lifestyle, activity levels, body image and mental/physical capacities. Those are the things that should go into decision making. It’s also important to consider age, functional state, caregiver support at home, and what kind of help with management of the urinary diversion is available. For example, having a complex diversion but living three hours away from a good hospital isn’t something I would advise.
For all of them, you can have a high level of activity if you were active prior to the bladder surgery. One can maintain activity levels, functional levels, and possibly sexual function based on the operation they undergo and their disease state. All these things are still possible. The main goal is to have excellent urinary function that won’t compromise quality of life.
At the U-M Multidisciplinary Urologic Oncology Clinic our patients are cared for by nationally recognized experts – urologists, medical oncologists, radiation oncologists and pathologists – as well as nurse practitioners and physician assistants who specialize in the treatment of bladder cancer. Each member of our team is committed to the best possible treatment for our patients.
The University of Michigan Comprehensive Cancer Center’s 1,000 doctors, nurses, care givers and researchers are united by one thought: to deliver the highest quality, compassionate care while working to conquer cancer through innovation and collaboration. The center is among the top-ranked national cancer programs, and #1 in Michigan for cancer patient care. Seventeen multidisciplinary clinics offer one-stop access to teams of specialists for personalized treatment plans, part of the ideal patient care experience. Patients also benefit through access to promising new cancer therapies.