Japanese Journal of Clinical Oncology Advance Access originally published online on September 26, 2006
Japanese Journal of Clinical Oncology 2006 36(11):717-722; doi:10.1093/jjco/hyl100
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© 2006 Foundation for Promotion of Cancer Research
The ‘Pitcher Pot’ Ileal Neobladder: Early Experiences
Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
For reprints and all correspondence: Sudhir Rawal, Department of Urooncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi 110085, India. E-mail: dr_rawal{at}yahoo.com
Received May 11, 2006; accepted July 9, 2006
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Abstract |
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 TOP Abstract INTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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OBJECTIVE: To analyse initial results of newly designed ileal neobladder—a modification of Studer neobladder
METHODS: Twenty-four patients with urinary bladder cancer underwent radical cystoprostatectomy from February 2005 to March 2006. Twenty-one of them had urinary diversion using ileal neobladder in spherical configuration with ileal neourethra (giving the shape of an inverted Indian earthenware container called a ‘pitcher pot’) to circumvent the problem of short mesentery and construct a low-pressure spherical ileal neobladder.
RESULTS: Early post-operative complications occurred in 42% of patients. Late complications occurred in 23% of patients. Most of these complications were minor, mainly as a result of wound infection, urine leak or urinary tract infections and were managed conservatively. No early post-operative mortality was observed. Daytime continence was achieved in 100% of patients who completed the 1 year follow-up. Night-time continence was variable as it depended on timed voiding—75% of patients achieved nocturnal continence by 1 year. The functional neobladder capacity was 426 ml. The mean post-operative residual volume was 36 ml. Three patients required cystoscopic mucus evacuation and catheterization. None of them required clean intermittent catheterization. No significant metabolic disturbance occurred in any patient.
CONCLUSIONS: Length of mesentery remains one of the factors in deciding the segment of intestine to be taken for neobladder. Ileal neourethra gives about 2–3 cm extra length to perform tensionless anastomosis, which is a key factor in the smooth recovery after such major surgery and also maintains optimum urodynamic features of neobladder.
Key Words: invasive bladder cancer • neobladder • ileum, continence • short mesentery
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INTRODUCTION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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Camey first described an orthotopic urinary reservoir in which a small tubular bowel segment was used as a bladder substitute by anastomosing it to the urethra (1). After Camey, several surgeons have designed different types of neobladder using different segments of gastrointestinal tract (2–5). Choosing the segment and type of neobladder depends on surgeons' preferences, ease of construction and length of mesentery. In our earlier experience with Studer ileal neobladder we encountered the problem of short mesentery in four patients out of 90 radical cystectomy patients and thus had difficulty anastomosing the neobladder to the urethra for anastomosis after construction of the neobladder despite using all described techniques. Other authors have also encountered a similar problem with neobladder techniques (6,7). Hence, we looked for new techniques to combat this problem by using part of the ileal wall to make a tube or neourethra and then folded the rest of the detubularized ileum in Heineke Mikulicz fashion thus creating a spherical shape neobladder with tube (neourethra) providing extra length for anastomosis without tension. We also made few other observations and modifications to decrease post-operative morbidity and improve short and long-term results. We analysed the peri-operative morbidity and early results in our patients.
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PATIENTS AND METHODS |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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From February 2005 to March 2006, 24 male patients underwent radical cystoprostatectomy for carcinoma urinary bladder. Two patients who underwent urethrectomy and one patient who had poor performance status underwent ileal conduit urinary diversion. The remaining 21 patients underwent ileal neobladder reconstruction using the technique described below. The histopathology was transitional cell carcinoma in 18 patients, round cell tumor in two patients and neuroendocrine tumor in one patient. The tumor stage ranged from T1G3 to T4a and two patients had N1 disease. The indication and contra-indications to the orthotopic reconstruction followed the criteria set by international consensus meetings on bladder cancer (8).
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SURGICAL TECHNIQUE |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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Initially the most dependent part of terminal ileum is marked by a marker suture at least 45 cm proximal and preferably 50–60 cm to ileocaecal junction so as to preserve at least 25 cm of ileum at ileocaecal junction as described subsequently to avoid gastrointestinal problem. Twenty centimetres of ileum distal and 35 cm of ileum proximal to marker suture are chosen to harvest the 55 cm segment of ileum. Distal 40 cm of segment is used to construct the neobladder and proximal 15 cm is used as afferent limb. Distal 40 cm ileum is cut at the antimesenteric border for detubularization. The incision turns towards the mesenteric border 2 cm on either side of the marker suture, thus creating a tongue-like flap at the marker suture (Fig. 1).
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The medial borders of incision are closed in longitudinal fashion with 3-0 PDS continuous suture and 3-0 interrupted vicryl suture in single layer to form the posterior wall of neobladder. The tongue-like flap at the apex of U-shaped ileum is closed in a tube-like fashion with 4-0 vicryl continuous sutures resulting in lumen sufficient to accommodate a 22 Fr Foley catheter. Thus about 3 cm of tube is formed resulting in a neourethra that is to be used for anastomosis. With a 3-0 PDS suture proximal most ends of the posterior longitudinal suture line are brought down to the distal end of anterior suture line thus folding the bladder in Heineke Mikulicz fashion and giving it a spherical shape with a tube (neourethra). After transposition of the left ureter to the right side, the ureters are spatulated and anastomosed by running PDS 4-0 sutures using the Nesbit's technique in an end to side fashion to proximal non-detubularized segment of ileum. Ureters were stented with 7 Fr feeding tube and are negotiated across ureteroileal anastomosis and brought out of the bladder through non-detubularized afferent limb towards the mesenteric side.
The anterior wall is closed transversely with PDS 3-0 continuous and Vicryl 3-0 interrupted sutures. Finally, the neourethra is anastomosed to the prostatic urethra with eight interrupted 2-0 monocryl sutures on Uroneddle over a three-way 22 Fr Foley catheter. The ureteric splints are brought out of the anterior abdominal wall on the right side and a urostomy bag is applied over it for urine collection. This neobladder, on filling, resembles the inverted ‘pitcher's pot’, which is an earthenware container used to store water in summer on the Indian subcontinent. No supra pubic catheter is placed. The pelvis is drained with a 28 Fr tube drain. A catheter is fixed to the glans.
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POST-OPERATIVE CARE |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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The neobladder is slowly and continuously irrigated with normal saline through an irrigation channel of three-way Foley catheter. The neobladder is flushed with 500 ml normal saline mixed with 25 ml 5% povidone iodine twice daily through the Foley catheter and thus mucus clots are aspirated. We do not perform stent study and post-operative cystogram routinely. Stent study is performed only when ureteroileal leak is suspected following increased urine drainage in the abdominal drain. The splints are removed on the 12th post-op day and the Foley catheter removed on 13th post-op day. The patient is taught perineal exercises and pelvic relaxation techniques. Patients are instructed to void in the sitting or standing position (whichever they find most comfortable) first by relaxing the pelvic floor and if necessary, by abdominal straining so that they are able to empty the bladder completely. Patients are encouraged to take more than 2 l of fluid per day and take additional dietary salts. The capacity of the bladder increases gradually with time. Patients are started on oral soda mint tablets once they are on oral diet to reduce the production of mucus.
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FOLLOW-UP |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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Each patient was evaluated initially 6 weeks after surgery and then at 3-monthly intervals. Ultrasound abdomen, chest X-ray and determination of serum electrolytes, blood urea, creatinine and liver profile were performed at each visit. Radiological investigations included gravity pouchography after 6 months and excretory urography after 12 months. Computed tomography of abdomen and pelvis was done in suspected cases of local or distal tumour progression. Urethroscopy was reserved for patients who developed urinary retention. Urodynamic study was carried out at 12 months.
Complications
Complications were classified as early (2 months or less post-operatively) or late (more than 2 months post-operatively). The complications were further subdivided into those directly and not directly related to the neobladder.
Continence and Voiding Patterns
Micturition/continence were assessed in a standardized manner using a detailed questionnaire, which served as a guideline for structured patient interviews. Continence was described as satisfactory if patients were completely dry and required no pads. Continence was described unsatisfactory if they used one or more pads during day or night.
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RESULTS |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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In this study, 21 patients underwent ileal low-pressure neobladder substitute, which had a few modifications over that described by Studer et al. (4,5). All patients were male with a median age of 52 years (range 38–68 years). All operations were done for carcinoma urinary bladder. In 19 patients bilateral nerve sparing radical cystoprostatectomy was done and in two patients only unilateral nerve preservation was done because of local findings. The median operating time required to perform the entire procedure was 5 h 20 min (range 4 h 20 min to 6 h 30 min). The median estimated blood loss was 1112 ml (range 475–2385 ml). The median post-operative hospital stay for these patients was 18 days. The mean follow-up was 6.5 months (range 3–13 months). Thirteen patients completed follow-up of 6 months and 4 patients completed follow-up of 1 year during the study. There was no operative mortality related to the surgery. Two patients died within 13 months post-operatively but the cause of death was unrelated to the neobladder procedure. One of these patients had recurrent disease, whereas the other patient died of unrelated disease.
Early complications occurred in nine patients (42%) of which four were related and five unrelated to the neobladder (Table 1). Re-operation in the peri-operative period was required in one patient for dehiscence of intestinal anastomosis requiring ileostomy on the ninth post-operative day. One patient had prolonged ileus, which was managed conservatively and lasted for 10 days post-operatively. No obvious cause was found. Two patients had prolonged urine leakage from the pouch through the drain tube and hence the Foley catheters were removed on the 18th and 20th post-operative days respectively and the drain on the subsequent day. Three patients developed minor wound infection that did not result in prolongation of stay. One patient developed UTI following catheter removal, which was managed with intravenous antibiotic injection. One patient developed urinary retention on the second day after catheter removal for which catheterization was attempted, but it failed. He underwent cystoscopy and mucus evacuation as he had retention because of excessive mucus. Following removal of the catheter after 3 days he voided well.
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Late complications followed in five patients (23%). Two patients developed urinary retention at 3 months and 6 months following surgery respectively. They required cystoscopic mucus evacuation and Foley catheterization. Following catheter removal after a week, both patients voided well and did not require intermittent catheterization. Of four patients who had pre-operative dilatation of one renal unit, each maintained their dilatation post-operatively without further deterioration. One patient who did not have pelvicalyceal dilatation pre-operatively developed dilatation of one renal unit but intravenous urogram did not show any ureteroileal obstruction. Mild pelvicalyceal fullness in follow-up ultrasonography is common without deterioration of renal function. One patient had high residual urine and a poor uroflow rate at the 6-monthly follow-up. Cystoscopy revealed prolapsed mucosa in neourethra obstructing the passage, which was resected using electrocautrey with cutting loop. After removal of the catheter the patient was voiding to satisfaction and post-void residual urine was negligible. One patient developed incisional hernia after 6 months follow-up.
None of the patients developed bowel obstruction, neobladder calculus, ureteroileal stricture or anastomotic stricture. None of the patients had clinically significant metabolic disturbances. All patients maintained normal renal function.
Continence gradually improved with time and most patients became satisfactorily continent especially during daytime by 6 weeks post-operatively. Daytime continence improved quickly after surgery. Six months after surgery 11 of 13 patients (85%) were completely dry in daytime. Four patients who completed one year, all (100%) were continent during daytime. At all times night-time continence rates are lower than daytime rates. Patients who follow timed voiding during the night used an alarm clock to maintain better night-time continence. Ten out of 13 patients (62%) at 6 months and three out of four patients (75%) at 1 year were continent during night.
Bladder capacity gradually increased over the months, thus decreasing the frequency of voiding. Functional reservoir capacity as assessed by frequency volume charts increased rapidly in the first few months. Average functional reservoir capacity was 386 ml after 6 months and 426 ml after 1 year. Average post-void volume as measured by abdominal ultrasonography was 30 and 36 ml after 6 months and 1 year respectively. The urodynamic study done at 12 months shows the average pressure at maximum capacity of 32 cm H2O and average peak voiding pressure of 59 cm H2O. Uroflowmetry performed at the same time showed an average peak flow of 15.7 ml/s (range 8.4–24.4 ml/s) and an average flow of 5.8 ml/s. The voiding pattern was variable—few having near normal voiding whereas others voiding mainly by straining (Fig. 2).
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DISCUSSION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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During designing a urinary reservoir, one must choose a design that provides characteristics similar to those found in normal bladder, including a low-pressure pouch with adequate compliance and capacity, preservation of upper tracts by avoiding reflux and obstruction of ureters, the ability to empty, and day and night-time continence (9). It is important that the ileum reaches the membranous urethra without causing tension on anastomosis. We found that the neourethra constructed by this method results in technically easier anastomosis and also avoids abandoning neobladder procedure in those patients in whom otherwise this procedure was not possible owing to short mesentery.
The pouch modified from that of Studer et al. (4) fulfils the above-discussed characteristics and offers further advantages. The use of isoperistaltic limb of ileum as an anti reflux mechanism offers the advantage of easily constructed uretero-intestinal anastomosis with low incidence of reflux and deterioration of upper tracts. To date, out of 42 renal units, only one renal unit has shown deterioration. This rate of upper tract preservation is excellent in the short period and longer follow-up is clearly indicated to assess upper tract preservation.
The spherical shape achieved by the Heineke Mikulicz technique from a detubularized segment of ileum results in a low-pressure spherical bladder with maximized volume to surface area ratio, which allows use of less intestinal length for a given pouch capacity and therefore minimizes the receptive surface area (10). None of our patients had metabolic or functional complications though long-term results need to be followed. Sparing at least 25 cm distal ileum aids in vit B12, folate and biliary acid absorption (9).
We have made minor modifications to the technique as it was described by Studer et al. We did not insert a suprapubic tube and relied on a single three-way urethral balloon catheter. This modification has come out of our earlier experience with neobladders where we used a routine supra pubic catheter which did not provide any extra advantage and one patient required exploration for persistent neobladder cutaneous fistula. Instead we relied on continuous irrigation through the three-way Foley channel. Similar modification was carried out by others also resulting in a decrease in suprapubic cystostomy-related morbidity (11). The other modification involved making a tube from bowel wall at the most dependent part of the pouch. Studer et al. had used a 5 cm tubular segment (non-detubularized terminal end) between the pouch and the membranous urethra in five patients. Two patients had intermittent pressure peaks resulting in incontinence (12). Abd Alla et al. used a shorter tube of 2 cm length and did not find any pressure peaks (11). We have used a reconfigured tube of bowel wall and hence pressure peaks are unlikely as shown by our urodynamic study. Smith et al. have discussed neourethral modification in association with Hautmann orthotopic bladder replacement with a chimney (13). In median follow-up of 17 months, 12 of 17 of their patients were completely continent day and night. There was a relatively higher incidence of requirement of intermittent catheterization (42%) for chronic retention in their study. We did not find this problem with our modification of the neourethra with the Studer neobladder. The third modification is selection of bowel segment. The benefits of a 40 cm ileum pouch and a 15 cm afferent limb have been well discussed (11,14). We selected a bowel segment that is most dependent and reaches pubic symphysis and still preserves at least 25 cm of ileum at the ileocaecal junction.
We have observed that the most dependent part of ileum may not always correspond to that after leaving 25 cm of bowel at the ileocaecal junction. Usually the most dependent ileum is 10–15 cm proximal to this part. We have observed that if the part of ileum before detubularization reaches pubic symphysis it will definitely reach membranous urethra after pouch reconstruction without tension with this technique. The last modification is not closing the distal end of the ileum and using this for making the pouch. This has been discussed by Benson et al. They attributed better continence rate to the somewhat larger capacity of the neobladder by this technique.
The early and delayed complications are comparable with other studies. Hautmann et al. in a review of 363 patients found early and late complications in 39.1 and 32% of patients respectively (15). Tanaka et al. reported delayed complications in 54.5% of patients while evaluating results of 53 patients who underwent Studer neobladder with a mean follow-up of 57 months (16). The late complications are less in our study. One reason for this may be shorter follow-up.
The high rate of daytime and night-time continence can be attributed to use of preserved sphincteric complex and compliance and low-pressure nature of pouch and neourethra. Studer et al. reported continence rates in patients 50 years or younger to be 100% in daytime and 86% at night with a reservoir capacity of 493 ml (14). The daytime and night-time continence in patients above 60 years in the same series was 90 and 65% respectively. Benson et al. reported similar continence rates (9). Our continence rates are comparable to these series, which may partly be due to reservoir shape. The attribution of neourethra to continence/voiding is yet to be ascertained in longer follow-up.
This bladder substitute appears to be technically easier and versatile. The ureteroileal anastomosis and anti reflux mechanism are identical to those used for construction of Bricker ileal conduit. One can argue against neourethra for probable high pressure voiding because of extra tube. However, during urodynamic study we have not found high pressure. The problem that we have faced is of unexpected high incidence of retention caused by mucus, which required cystoscopy in three patients. The long-term follow-up of these cases will determine the fate of this new technique although initial results are very encouraging. The resemblance of shape of this modified neobladder with ‘pitcher pot’ justifies its nomenclature as ‘pitcher pot ileal neobladder’ (Fig. 3).
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CONCLUSIONS |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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Among various methods used to construct orthotopic urinary reservoirs, no single technique is ideal for all patients or clinical situations. The goal is to provide a functionally acceptable neobladder with low complication rate and ultimately enhance quality of life. The pitcher pot ileal neobladder as described here fulfils various criteria of bladder substitute and has fewer complications especially by providing 2–3 cm of extra length of neourethra for tension free anastomosis. The long-term follow-up of these cases will determine the fate of this technique.
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References |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSSURGICAL TECHNIQUEPOST-OPERATIVE CAREFOLLOW-UPRESULTSDISCUSSIONCONCLUSIONSReferences |
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2 Koch NG, Ghoneim MA, Lycke KG, Mahran MR. (1989) Replacement of the bladder by the urethral Koch pouch: functional results, urodynamics and radiologic features. J Urol 141 1111–4.[Web of Science][Medline]
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7 Bassiouny M, Zaghloul AS, Sherbiny ME, Saber N, Abdalla H, Shokry A. (2004) Detubularised sigmoid neobladder versus detubularised W-shaped ileal neobladder as a bladder substitute after radical cystectomy for carcinoma of the urinary bladder: a study of 60 patients. J Egypt Nat Cancer Inst 16 76–84.
8 Studer UE, Hautmann RE, Hohenfellner M, Mills RD, Okada Y, Rowland RG, Tobisu K, Tsukamoto T. (1997) Indications for continent diversion following cystectomy and factors affecting long term results. Presented at Fifth International Consensus Meeting on Bladder Cancer, Tokyo, Japan.
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11 Abd Alla HM and Attia AA. (2000) Lower urinary tract reconstruction following radical cystectomy using ileal neobladder with Studor technique; 3 years experience. J Egypt Nat Cancer Inst 12 235–43.
12 Studor UE, Danuser H, Merz VW, Springer J, Zingg EJ. (1995) Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol 154 49–56.[CrossRef][Web of Science][Medline]
13 Smith E, Yoon J, Theodorescu D. (2001) Evaluation of urinary continence and voiding function: early results in men with neourethral modification of the Hautmann orthotopic neobladder. J Urol 166 1346–9.[CrossRef][Web of Science][Medline]
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15 Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Matters R, Paiss T. (1999) The ileal neobladder: complications and functional results in 363 patients after 11 years of follow-up. J Urol 161 422–8.[CrossRef][Web of Science][Medline]
16 Tanaka T, Kitamura H, Takahashi A, Masumori N, Itoh N, Tsukamoto T. (2005) Long-term functional outcome and late complications of Studer's ileal neobladder. Jpn J Clin Oncol 35 391–4.
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