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Complications in Orthotopic Neobladders
KathrinMeisterhofer, BastianAmend,
andArnulfStenzl
14
Introduction
In women, radical cystectomy includes removal of
the urinary bladder, distal ureters, uterus, proximal
two-thirds of the vaginal anterior wall, both ovaries, and pelvic lymph nodes. Depending on tumor
location, patients’ age, and indication, the vaginal
anterior wall and ovaries may be preserved.
The most common indication for cystectomy
in women is cancer of the urinary bladder. Other
indications for bladder removal are gynecological tumors or colon carcinoma, although orthotopic bladder replacement is usually not an option
in these cases due to the locally advanced growth.
Nononcological indications for cystectomy are a
small-capacity bladder, post-radiogenic cystitis,
and interstitial cystitis.
Urinary diversions are divided into continent
and incontinent (ileal conduit, ureterocutaneostomy) solutions. Continent urinary diversions can
be subdivided into orthotopic and heterotopic
(catheterizable pouches) approaches. This chapter focuses on complications of orthotopic ileal
neobladders.
Over time, many different forms of neobladders have been described and modied by surgeons. The variants of neobladders differ in terms
of folding techniques of the bowel and reuxing
or nonreuxing implantation of the ureters.
Cystectomy with urinary diversion can be performed either by open surgery or robot-assisted
laparoscopy. The complication rate, oncological
outcome, and quality of life are all similar for
both robotic and open approaches. The surgeon’s
experience and institutional volume are more
important for the outcome than the technique [1].
Therefore, the procedure should only be performed at specialized centers.
The perioperative mortality rate after radical
cystectomy is 2.1–3.2% at 30days and 3.4–8% at
90days [2, 3]. Complications can be categorized
as early postoperative complications and longterm complications. Therefore, a lifelong follow up is needed after a neobladder reconstruction.
This chapter summarizes the complications of
orthotopic ileal neobladders and their
management.
K. Meisterhofer · B. Amend · A. Stenzl (*)
Department of Urology, University Hospital of
Tuebingen, Eberhard Karls University,
Tuebingen, Germany
e-mail: kathrin.meisterhofer@med.uni-tuebingen.de;
bastian.amend@med.uni-tuebingen.de;
uro@stenzl.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_14
Early Postoperative Complications
Perioperative Bleeding Intraoperative bleeding may occur during cystectomy in women,
especially at the vaginal venous plexus. It corresponds to the prostatic venous plexus in men.
137
138
ab
K. Meisterhofer et al.
Various hemostyptics can be used. In case of
increased blood loss and coagulation disorders,
transfusion of red blood cells, platelets, fresh
frozen plasma, and specic coagulation factors—depending on specic diagnostics—
should be considered. In case of unmanageable
intraoperative bleeding, “packing” of the surgical area and a second-look surgery within 72h
can be performed.
If postoperative bleeding is suspected, due to
hemodynamic instability, increased bloody
drainage volumes, drop in hemoglobin, or free
uid in sonographic examination, CT scanning
should be performed to localize the hemorrhage.
Before immediate surgical revision, the possibility of angiographic embolization of the bleeding
should be evaluated.
Ileus or Bowel Obstruction An ileus is
described in up to 26.9% of cases after radical
cystectomy [4]. It may be caused by peritoneal
irritation due to peritonitis or urine leakage, adhesion formation, or herniation of intestinal loops.
Enteral and parenteral bowel stimulation by indirect parasympathomimetic drugs is essential in
the early postoperative period. If an inserted nasogastric tube is used, it should be removed as early
as possible because its irritation might have a
negative inuence on bowel recovery. The diagnosis of ileus is made clinically or by imaging.
Paralytic ileus can be treated conservatively with
forced bowel stimulation and reinsertion of a gastric tube. If a mechanical obstruction is highly
probable, a surgical revision is indicated.
Insufciency of Intestinal Anastomosis There
are different techniques for performing intestinal
anastomosis. While stapled side-to-side or endto- side anastomosis is technically faster and easier to perform, handsewn end-to-end anastomosis
preserves the straight ow of the intestinal contents and should therefore be preferred.
Insufciency of intestinal anastomosis is
clinically manifested by acute abdominal pain.
In addition, air or even stool appears in the
drainage. An immediate surgical revision is
indispensable in this potentially lethal complication (Fig.14.1).
Insufciency of Urological Anastomosis and
Suture Lines The various urological anastomo-
ses include the sutures between the ureter and
neobladder and the urethra and neobladder or
those of the neobladder itself. Clinically, suture
insufciency is manifested by an increased ow
rate of the drainage. Therefore, the creatinine
level in the drainage should be compared to the
serum level. If the levels are identical, a major
insufciency is unlikely. In addition, a radiographic exclusion of leakage (conventional cys-
Fig. 14.1 Insufciency of intestinal anastomosis
ab
14 Complications in Orthotopic Neobladders
139
togram) should be performed before removing
the inserted catheter.
In case of insufciency, a conservative
approach with low-pressure drainage should be
pursued. If necessary, stents that have already
been removed (e.g., catheter, ureteric stents, or
additionally nephrostomies) must be reinserted.
Surgical revision is rarely required. However,
suture insufciency leads to an increased risk of
tubular stricture (Fig.14.2).
Vesicovaginal Fistula To avoid a stula between
the vagina and neobladder or anastomosis, the
suture lines should be kept distant. In addition, an
omental ap is usually created and placed around
the lowest part of the neobladder. This prevents
stula formation and suspends the neobladder
oor, reducing the risk of urinary retention by
preventing ileal fold formation, as mentioned
below (Fig.14.3).
Fig. 14.2 An inconspicuous cystogram (a). Insufciency of the ureteroileal anastomosis (b)
ab
Fig. 14.3 To avoid a vesicovaginal stula (a), an omental ap should be placed around the neobladder (b)
140
ab
K. Meisterhofer et al.
Urinary Tract Infections (UTIs) Urinary tract
infections (UTIs) are one of the most common
problems in urinary diversions. They should be
rst ruled out before reconstructive urological
surgery. In addition, it is recommended to check
for signicant bacteriuria before removing catheters or stents to reduce the risk of febrile UTI,
which can be life-threatening.
Long-Term Complications
Urinary Incontinence Daytime and nighttime
continence rates in women with an orthotopic
neobladder range from 82 to 95% and from 72 to
86% and are comparable to male patients [5].
For a good functional result, intraoperative
preservation of the autonomic nerve bers is
mandatory. While the external urinary sphincter is innervated by the pudendal nerve, the
proximal urethra is also innervated by sympathetic nerves. The sympathetic nerves originate
from the sympathetic trunk and reach the pelvis through the superior and inferior hypogastric plexus, with additional bers arising
directly from the sacral nerves. The bers run
in front of the common iliac artery and medial
to the ureter. If acceptable from an oncological
point of view, it is important to preserve these
bers, especially when performing a pelvic
lymphadenectomy.
Furthermore, dissection of the bladder neck is
essential for preservation of continence. If the
urethra is cut too short, there is a decit of sphincter tissue, resulting in stress urinary incontinence.
However, leaving a too long urethral segment
might result in urinary retention. Therefore, the
urethra should be dissected 5mm below the bladder neck (Fig.14.4).
To assess incontinence, a medical history
(preexisting incontinence increases the risk),
physical examination, and sonography (differential diagnosis is overow incontinence due to urinary retention) should be performed rst. In
patients with an orthotopic neobladder, in whom
the surgical principles of detubularization and
reconguration to achieve a low-pressure reservoir were not adhered to, urodynamic diagnostics
can determine the increased pressures and thus
the indication for revision surgery.
Fig. 14.4 Bladder neck dissection: A Foley catheter (virtually superimposed) helps identify the bladder neck (a).
Dissection 5mm below the bladder neck (b) (with permission from John Wiley and Sons [6])
14 Complications in Orthotopic Neobladders
141
Conservative treatment options for incontinence are pelvic oor exercises with or without
biofeedback and electric stimulation. However,
the improvement depends on the patient’s compliance. Duloxetine, a serotonin and noradrenaline
reuptake inhibitor, is currently the only pharmaceutical treatment option for incontinence. There
are only limited surgical options available for
treating stress urinary incontinence in women
who have undergone orthotopic neobladder
replacement. While bulking agents may provide
temporary relief, the use of tension-free vaginal
tapes is associated with a high risk of perforation.
In cases of refractory stress urinary incontinence,
diversion into an ileal conduit or a catheterizable
continent reservoir may be the last option.
Urinary Retention Various causes of post-void
residual urine have been identied in patients with
neobladders (Fig. 14.5). Ileal folds, anastomotic
strictures, tumor recurrence, and prolapse can lead
to outlet obstruction. The nerve-sparing approach
and dissection of the urethra have already been
described above. Preservation of urethral vascularization in bladder neck dissection is also mandatory. To avoid kinking of the reservoir outlet, a
separate buttonhole should be created at the most
caudal point of the pouch for the ureteroileal anastomosis while creating the neobladder.
Cystoscopy is a main component in the diagnosis
of bladder emptying disorders. Strictures and
intestinal folds can be transurethrally resected.
Urinary retention may cause recurrent UTIs and
cystolithiasis and can damage the upper urinary
tract with impairment of the renal function.
Urinary retention often results in long-term intermittent aseptic catheterization. The rate of residual
urine with an indication for intermittent aseptic
catheterization is more common in female patients
(0–53%) than in men (4–33%) [7] (Fig.14.6).
Ureteric Strictures Ureteral strictures usually
occur distal to the implantation in the neobladder
and were reported in 2.7–3.8% of cases [5]. To
avoid ureteric strictures, it is essential to maintain
the vascular and nerve supply of the ureters
(Fig. 14.7). As already described above, suture
insufciency at the ureteral implantation site
increases the risk of strictures. In case of hydronephrosis, renal scintigraphy should be performed
to differentiate between chronic ectasia without
urodynamic problems and signicant hydronephrosis. If an obstructive outow is detected, a
double J (DJ) stent or a nephrostomy tube (in
patients with challenging retrograde instrumentation) should be inserted, to protect the upper urinary tract from further damage. The only way to
cure the stricture would be a surgical revision.
Fig. 14.5 Causes of
urinary retention
142
ab
K. Meisterhofer et al.
abc
Fig. 14.6 An obstructive ileal fold (a). Transurethral resection of the fold (b). Postoperative result with a wide outlet
of the neobladder (c)
Fig. 14.7 To avoid ureteric strictures (a), it is essential to maintain the vascular and nerve supply of the ureters (b)
(specimen from K.Colleselli)
Sexual Dysfunctions Sexual dysfunctions
include decreased desire, decreased lubrication
of the vagina, decreased ability to achieve an
orgasm, and dyspareunia. The disorders were
reported at rates of 49%, 9.5%, 39%, and 25%,
respectively, after cystectomy [8].
Devascularization of the surrounding neurovascular bundles of the vagina and clitoris and
shortening of the vaginal length cause sexual
dysfunction after cystectomy. Therefore, preservation of autonomic nerve bers is not only
important for continence but also for sexual
offered. The incidence of sexual dysfunction
was reported in 10% of patients receiving sexual organ- or nerve- sparing cystectomy and in
59% receiving radical cystectomy [8]. In addition, bilateral removal of the ovaries leads to
impairment of sexual functions, especially in
young patients. Accordingly, preservation of an
ovary should be discussed preoperatively; the
removal of the fallopian tube, including the
mbrial funnel, is recommended with regard to
the prevention of ovarian carcinoma (opportu-
nistic salpingectomy).
function. The nerve-sparing approach has
already been described above. Radical cystectomy includes resection of the uterus and part
of the anterior wall of the vagina. A longitudinal re- tubularization of the vagina increases the
depth of the vagina compared to a transversal
closing but may result in a narrow lumen, causing dyspareunia. In benign indications for cystectomy, a genital-preserving technique can be
Pelvic Organ Prolapse The incidence of vagi-
nal prolapse after cystectomy is 6–12% [9].
Patients may experience vaginal bulging, pelvic
pressure, difculty emptying the bowel or blad-
der, or sexual dysfunction. Management includes
conservative therapy such as vaginal pessaries or
surgery with transabdominal or transvaginal sus-
pension with or without mesh. However, there is
14 Complications in Orthotopic Neobladders
Fig. 14.8 Vaginal prolapse after cystectomy with neobladder replacement
no standardized recommendation for pelvic
organ prolapse with an orthotopic neobladder.
The combination of colpectomy and colpocleisis
represents a last resort in older patients who do
not wish to have sexual intercourse (Fig.14.8).
Urinary Tract Infections Patients with a neobladder do not have typical dysuric symptoms of an
UTI.A common symptom is increased mucus production. Residual urine often leads to UTIs and
stone formation, which, in turn, leads to recurrent
UTIs. In case of urinary diversions, the infections
are dened as complicated UTIs. Therefore, microbiological examinations should be performed, and
patients should be treated with antibiotic therapy in
sufcient dosage and duration (usually 7days).
Metabolic Imbalance Reabsorption of urine
through the intestinal mucosa of the neobladder
may lead to metabolic imbalance. It depends on
the length of the used intestinal segment, the
length of time the urine remains in the neobladder, and the pH and osmolarity of the urine.
Metabolic imbalance occurs mostly in the early
time period after catheter removal. Due to atrophy of the mucosa, reabsorption decreases over
time. Nevertheless, some patients have metabolic
problems even after years. Metabolic imbalance
causes symptoms like lethargy, confusion, mus-
143
cular weakness, fatigue, nausea, vomiting, or
abdominal pain. Therefore, blood gas analysis
should be performed regularly.
Patients who have an ileal reservoir tend to
develop hypochloremic acidosis, while those with
colonic segments tend to develop hyperchloremic
acidosis. Acidosis can be treated with sodium
bicarbonate. In cases of hyperchloremic acidosis,
patients may require potassium supplementation.
Chronic metabolic acidosis may cause bone
demineralization and therefore osteoporosis.
Malabsorption Reduced intestinal absorption
of vitamin D and calcium following ileal resection may also affect bone metabolism in urinary
diversions.
Vitamin B12 is absorbed in the terminal
ileum. Extensive use of this small intestinal
part can lead to decreased absorption.
Deciency may lead to anemia or severe and
irreversible neurological diseases (e.g., peripheral polyneuropathy, dementia, spinal cord
degeneration, optic atrophy). In people consuming a balanced diet, vitamin B12 is stored
in sufcient amounts in the liver. Hence, deciency may not become apparent for several
years. Screening for vitamin B12 deciency is
therefore recommended throughout life, and, if
a deciency is conrmed, parenteral supplementation is extremely important.
Bile acids are reabsorbed in the terminal
ileum. A shortened ileum can lead to chologenic
diarrhea. In this case cholestyramine bind bile
acids thereby relieving these symptoms.
Short Bowel Syndrome In addition to malabsorption, the use of a long bowel segment for urological reconstruction can result in faster bowel
transit time. This can lead to increased stool frequency and diarrhea. Loperamide or opium tincture can improve the amount and frequency of
diarrhea (Fig.14.9).
Psychological Effects Surgery can also have
psychological effects on patients, especially
when they experience complications or have difculties in adjusting to their neobladder.
Symptoms may include anxiety, depression, or
144
K. Meisterhofer et al.
blood gas analysis to detect anemia, increased
renal function, vitamin deciency, and metabolic
imbalance. If an UTI is suspected, a urine culture
should be obtained. Ultrasound should be performed to exclude residual urine and hydronephrosis. CT scans or MRI should be performed
according to the oncological follow-up plan in
case of an underlying malignancy.
References
Fig. 14.9 The use of a long bowel segment for neoblad-
der reconstruction increases the risk of short bowel syndrome. The I-Pouch neobladder requires only 40cm of
the terminal ileum, whereas other techniques require up to
70cm of the intestine [10, 11]
feelings of isolation or frustration. Treatment
options may include therapy or medication to
manage symptoms as well as support from relatives or support groups.
Conclusions
In summary, to avoid all these early and longterm risks and complications, after cystectomy
and orthotopic bladder replacement, patients
benet from standardized perioperative management and need a close and lifelong follow-up.
The use of a fast-track program reduces morbidity and improves early recovery [12]. This
concept includes, e.g., sufcient pain management, including epidural anesthesia, early mobilization, and early removal of the gastric tube for
bowel recovery. The drainages and catheter
should be removed after exclusion of leakage, as
described above. In addition, a prophylaxis of
thrombosis and pulmonary embolism is essential
in the early postoperative time.
During follow-up, the anamnesis should cover
drinking and voiding behavior as well as catheterization frequency if performed. In addition,
sexual anamnesis and questions about quality of
life should be included, to recognize psychological problems at an early stage.
Blood tests should focus on hemoglobin, creatinine, electrolytes, vitamin B12, and venous
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