How to Obtain Good Results with Orthotopic Bladder Substitution: The 10 Commandments

Context: The orthotopic neobladder has not only withstood the test of time but is increasingly becoming amore desirablemethod of urinary diversion. Complementing orthotopic neobladder features with adequate training allows patients to return to a urinary routine that is close to, if not completely, normal. Objective: The preconditions, indications, and contraindications as well as the key points of the surgical technique will be presented by researchers who pioneered this operation. Evidence acquisition: Experience with and long-term follow-up of orthotopic reconstruction is presented by surgeons at institutions that pioneered orthotopic reconstruction during the last 25 yr with a high surgical volume of radical cystectomy (RCX) and any form of urinary diversion (particularly orthotopic reconstruction). Evidence synthesis: Ten commandments were developed for achieving good results with orthotopic bladder substitution: (1) The procedure should be performed by a high-volume surgeon; (2) do not overextend the indication; (3) experience with nerve-sparing radical prostatectomy and bowel surgery is mandatory; (4) use ileumwhenever possible; (5) maximum detubularisation is a must; (6) use a stented, freely refluxive ileoureterostomy; (7) the low-pressure, compliant, freely refluxive reservoir is standard; (8) be aware of myriad potential complications; (9) a full armamentarium of diversion techniques must be available; and (10) meticulous follow-up must be guaranteed. Conclusions: Continence and voiding function following orthotopic bladder substitution are determined primarily by characteristics of the reservoir and by a preserved, innervated outlet mechanism. The reservoir should be detubularised and compliant with a low end filling pressure. Ileum seems to be superior to sigmoid or stomach, which can be used when necessary but with higher incontinence rates. Reflux prevention is not a major concern and does not justify the use of an antireflux mechanism with a high complication rate. # 2009 European Association of Urology. Published by Elsevier B.V. All rights reserved.