Abstract
BACKGROUND: A long-term follow-up indicates that orthotopic ileal neobladder can cause acid-base balance and nutritional metabolic disorder. Otherwise, a long mesenterium is necessary to balance the tension of bladder at pelvic cavity and urinary inosculation due to a high position of ileum. On the contrary, sigmoid neobladder is near by urinary canal, and orthotopic sigmoid neobladder as a bladder substitute after radical cystectomy has few effects on acid-base balance of electrolytes, nutritional metabolism and secretion of mucus.

OBJECTIVE: To compare the clinical results of these two operations basis on long-term follow-up.

DESIGN: Retrospective analysis.

SETTING: Department of Urinary Surgery, the Second Affiliated Hospital of Kunming Medical College.

PARTICIPANTS: 164 patients with carcinoma of bladder were selected from Department of Urinary Surgery, the Second Affiliated Hospital of Kunming Medical College form January 1995 to March 2005. Ninety-six of them, including 74 males and 22 females, with age of 43-74 years and the average age of 65 years, accepted the operation of orthotopic ileal neobladder were regarded as the ileal neobladder group, and the other 68, including 64 males and 4 females, with age of 51-72 years and the average age of 62 years, accepted the operation of orthotopic sigmoid neobladder were regarded as the sigmoid neobladder group. All patients were finally diagnosed as pathological examination, and informed consent was provided by all patients. Treatment plan was approved by the local ethical committee.

METHODS: ① Orthotopic ileal neobladder: Once the bladder was removed, a segment of ileum about 40-60 cm in length was isolated. In the operative procedure, the distal part of ileum which connected to the caecum often kept, the length of which was 15-20 cm. Both distal ends of the ureters were anastomosed to the homolateral not been split end of the isolated bowel. A perforation was constructed at the bottom of the pouch which served as the outlet, this outlet was then anastomosed to the proximal portion of the remaining urethra. ② Orthotopic sigmoid neobladder: After surgically removing the bladder, a part of the sigmoid colon, the length of which was 30-40 cm was isolated. Other operations were as the same as those mentioned above.
MAIN OUTCOME MEASURES: Time of operation, blood loss during the procedure, length of time confined to bed, time of indwelling catheter, the ability to maintain continence and urinate, the results of urodynamic studies, and pouch related complications after operation.

RESULTS: In 164 patients, 12 (7.3%) were lost to follow-up. The mean follow-up times were 46 months in the group of orthotopic ileal neobladder and 42 months in the group of orthotopic sigmoid neobladder, respectively. Blood loss during the procedure and the ability to maintain continence and urinate were similar in the two groups (P > 0.05). Compared with sigmoid neobladder group, the ileal neobladder group spent more time on operation, keeping the bed and indwelling catheter. The max volume of ileal pouch was higher than that of sigmoid pouch, and the difference was significant in statistic analysis (t=2.56-3.08, P < 0.05-0.01). Incidence of complication of ileal pouch (16.7%, 29.2%) was higher than that of sigmoid pouch (9%, 16%). The incidence in the early phase was not significantly different, but that in the late phase was significantly different (χ2=5.426, P < 0.05).

CONCLUSION: Compared with orthotopic ileal neobladder, sigmoid neobladder is worthy of being preferred for its shorter operative time, faster recovery and lower rate of pouch related complications.

INTRODUCTION

In recent years, because of the excellent postoperative results of orthotopic neobladder, this operation is being accepted by more patients and urologists. At present, ileal and sigmoid neobladder are preferred by most of the urologists, however, no one can make it clear that which one of the two is superior. In order to compare the clinical results of these two operations, we followed up 164 patients who agree to the orthotopic ileal neobladder or sigmoid neobladder in our hospital, and the time extent from January 1995 to March 2005.

SUBJECTS AND METHODS

Subjects
164 patients with carcinoma of bladder were selected from Department of Urinary Surgery, the Second Affiliated Hospital of Kunming Medical College form January 1995 to March 2005. Ninety-six of them accepted the operation of orthotopic ileal neobladder were regarded as the ileal neobladder group, and the other 68 accepted the operation of orthotopic sigmoid neobladder were regarded as the sigmoid neobladder group. All patients were finally diagnosed as pathological examination, and informed consent was provided by all patients. The group of orthotopic ileal neobladder included 74 males and 22 females, and their ages ranged from 43 to 74 years with the average age of 65 years. In the total of 96 patients with bladder cancer, 92 had the histopathological diagnosis of transitional cell carcinoma, and the numbers of patients in each stage were 59 T1, 22 T2, 7 T3 and 4 T4. Two suffered from squamous cell carcinoma, and one from adenocarcinoma and another neuroendocrine cell
carcinoma. The group of orthotopic sigmoid neobladder was composed of 64 males and 4 females. Their ages ranged from 51 to 72 years with the average age of 62 years. In the total of 68 patients with bladder cancer, 66 were diagnosed with transitional cell carcinoma, the stages of which were 52 T1, 12 T2 and 2 T3. The other 2 patients had adenocarcinoma. Treatment plan was approved by the local ethical committee. The general condition of patients is shown in Table 1.

Methods
Orthotopic ileal neobladder: Once the bladder was removed, a segment of ileum about 40-60 cm in length was isolated. In the operative procedure, the distal part of ileum which connected to the caecum often kept, the length of which was 15-20 cm. The remaining ileum was reanastomsed, and the gap in the mesentery was closed. The isolated ileum was fold to the shape of "W", then this bowel was split at the sides contrary to the mesentery, however, at both ends of the bowel, a part of intestine about 8 cm long, was not split. The split bowel was then sutured to construct a "globose" pouch. Both distal ends of the ureters were anastomosed to the homolateral not been split end of the isolated bowel with utilizing an anti-reflux technique. A perforation was constructed at the bottom of the pouch which served as the outlet, this outlet was then anastomosed to the proximal portion of the remaining urethra.
Orthotopic sigmoid neobladder: After surgically removing the bladder, a part of the sigmoid colon, the length of which was 30-40 cm was isolated. The remaining proximal and distal ends of the colon were classically reanastomosed, thereby, reestablishing the continuity of the big bowel. The gap on the mesentery was then closed. The isolated sigmoid colon was folded in the shape of a "U", and the bowel was incised at the side contrary to the mesentery. However, the proximal end of the intestine, about 5-8 cm long, was not split. The split bowel was then sutured to make a pouch. Bilateral ureters were then anastomosed to the proximal end of the bowel which had not been incised. An anti-reflux technique was then performed, similar to that utilized for the orthotopic ileal neobladder. Finally, the bottom of the pouch was perforated to serve as the outlet. This opening was then anastomosed to the remaining urethra.
At the conclusion of the operation, the newly constructed pouch was irrigated with saline. This postoperative irrigation continued for 2-3 days. All patients were administered total parenteral alimentation (TPN) for 5-7 days.
Follow-up: The follow-up included: time of operation, blood loss during the procedure, length of time confined to bed, time of indwelling catheter, and the ability to maintain continence and urinate. Also included were the results of urodynamic studies, and pouch related complications after operation. The follow-up time in the group of orthotopic ileal neobladder lasted for 2 to 86 months, and the mean duration was 46 months; in addition, the follow-up time in the group of orthotopic sigmoid neobladder lasted for 4 to 78 years, and the mean duration was 42 months.
Statistical analysis: SPSS 11.5 software was used by the first author. Enumeration and measurement data were compared with Chi-square test and t test, respectively.

RESULTS

Quantitative analysis of the participants
Twelve patients (7.3%) were lost in the follow-up, 9 of them belong to the ileal neobladder group, and the other 3 belong to the sigmoid neobladder group. The average time of follow-up was 46 (2-86) months to ileal neobladder group and 42 (4-78) months to sigmoid neobladder group. In the follow-up, 18 patients (18.8%) accepted an ileal neobladder died, 3 of them died for recurrence and metastasis of the tumor and the other 15 ones for non-tumor reasons. Nine (13.2%) patients who accepted a sigmoid neobladder died in the follow-up, their death all caused by non-tumor reasons.

Comparisons of operative condition, postoperative short-term recovery, and follow up between the two groups (Table 2)
Compared with sigmoid neobladder group, the ileal neobladder group spent more time on operation, keeping the bed and indwelling catheter, the difference was significant (P < 0.05). The max volume of ileal pouch was higher than that of sigmoid pouch, and the difference was significant in statistic analysis (P < 0.05). Daytime and nocturnal continence rates in the ileal neobladder group were higher compared to sigmoid neobladder group, and there was significant difference in diurnal continence rate (P < 0.05), but no significant difference in nocturnal continence rate between the two groups (P > 0.05). Incidence of complication of ileal pouch was higher than that of sigmoid pouch. The incidence in the early phase was not significantly different, but that in the late phase was significantly different (P < 0.05).

DISCUSSION

Because of the low pressure of the detubularized ileal neobladder, and such merit of ileum as the length and long mesentery of which, ileum was the first choice in constructing a pouch in early times. However, long time followup has found the ileal pouch could cause an acid-base dysequilibrium and lead to nutritive disturbance. Moreover, the ileal mesentery often has insufficient length to adequately complete the anastomosis between the pouch and urethra. These disadvantages made some patients lost the chance to be a candidate of neobladder. Because the sigmoid colon is close to the urethra, which can make the anastomosis between the pouch and urethra surgically convenient. Further more, the sigmoid colon has little influence on the acid-base balance and nutrient metabolism, and can produce less grume than ileum[1-2]. Consequently, in recent years, the sigmoid neobladder has gradually been accepted by urological surgeons.

In our research, the operation time of ileal neobladder was longer than that of sigmoid neobladder. This might be caused by following reasons: we performed the ileal neobladder initially, and our operative technique was not so perfect at that time. Besides, the technique to make an ileal pouch was more complicated than that of sigmoid pouch, so we had to spend more time on this procedure. Moreover, compared with those patients subject surgically to the sigmoid neobladder, patients with an ileal neobladder spent more time at bed rest and indwelling catheter after the operation. These conditions might lead to the higher rate of early pouch related complications of ileal neobladder.
Both operative procedures result in excellent urinary continence. The rates of daytime continence of both groups were higher than those at night. However, there was no statistic difference in the rate of diurnal continence between these 2 groups, which was similar to other reports[3-5]. About 7 percent of patients of both groups suffered high continence after operation, this was caused by a stricture of the anastomosis between the pouch and urethra. An internal urethrotomy was employed to resolve this problem and the results were good. Regarding the high continence caused by grume obstruction, we washed the pouch with saline regularly. Several years later, the mucous membrane of the neobladder would atrophy gradually, and the number of goblet cell would decrease, so the excreting of grume would decline significantly[6].
In the postoperative urodynamic analysis, we discovered the average maximum volume of ileal pouch was higher than that of sigmoid pouch[7-8]. However, between these 2 groups, no statistic difference of the maximum pressure of the pouch, maximum flow rate and residual urine was found. The smaller pouch of sigmoid neobladder might be ascribed to the short intestine that sigmoid colon can provide. Subjectively, however, the patients found their sigmoid pouch was large enough, because which not only had satisfactory volume but also had acceptable low pressure[9-16]. Both groups had high residual urine, this might be caused by the low pressure of the pouch, the stricture of the anastomosis between the pouch and urethra, and the patients could not urinate properly. With these patients, we suggested them to empty the neobladder through regularly catheterizing, thereby declining the pressure and preventing infection. The rate of early and late pouch related complications of both groups were similar to those of other reports[3-5,7,12,15], however, the rate of ileal neobladder was higher than that of sigmoid neobladder. The higher rate of urine leaking and intestinal fistula of ileal neobladder might be caused by following factors: ① We performed ileal neobladder initially, and our technique was not so perfect at that time. ② The complicated technique to make an ileal pouch. The fistula of small intestine taking place in the patients of ileal neobladder can lead to the loss of a large quantity of digestive juices, and the failure to absorb nutrition. These patients often suffer such complications as acid-base dysequilibrium, electrolyte disturbance and poor wound healing, so their recovery will be obviously delayed.　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
Because the mucous membrane of small intestine has a strong ability to absorb and excrete electrolyte and absorb nutrition, electrolyte and nutritive disturbance often take place after the operation of ileal neobladder. Zhou et al[18] reported, in the animal tests, the number of Cl- that ileum absorbed from the urine was 1.47 times higher than that of cecum and colon, and the number of HCO3- that ileum excreted was 796.7% higher than that of colon. Repassy et al[2] also found the rate of acidosis was high after the operation of ileal neobladder. Giannini et al[19] reported that, in patients with ileal neobladder, a mild metabolic acidosis was responsible for a decrease of bone mineral density, moreover, a decrease over time in the absorption capacity of the ileal pouch might result in calcium malabsorption, which represents an additional risk factor for reduced bone mass in these patients. Because the VitB12 is actively absorbed by the distal ileum adjacent the cecum, therefore when a long segment of ileum was isolated from the small intestine, the ability of ileum to absorb the VitB12 would decline, the result would be megaloblastic anemia. In our research, the rates of metabolic acidosis and megaloblastic anemia occurring after employment of the ileal pouch was higher than those occurring in patients with the sigmoid neobladder, which is in accordance with other reports[1-2].

We discovered it in our clinical evaluation that the rate of malignant tumors occurring in the colonic segment is higher than that taking place in ileum. This presents as a major apprehension of surgeons to choose a sigmoid pouch[20]. In our research, the longest follow-up of which was 78 months, no tumor took place in the sigmoid neobladder, but malignant tumors were found in 3 ileal neobladders, and 2 of them were nontransitional cell carcinoma, which was different from the primary tumors of the excised bladders. More research is necessary to find out whether the ileal pouch trend to suffer a malignant tumor, our study at least can show, that the risk of the sigmoid pouch to suffer from a tumor is not higher than that of the ileal pouch.
In summary, orthotopic ileal neobladder and sigmoid neobladder are similar in operative difficulties, and both of them can acquire excellent clinical results. Compared with orthotopic ileal neobladder, sigmoid neobladder is worth being advocated for its shorter operative time, faster recovering and lower rate of pouch related complications.

REFERENCES

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原位回肠与乙状结肠尿流改道再造膀胱：10年资料回顾☆

詹 辉, 王剑松, 徐鸿毅, 石永福, 左毅刚, 杨德林, 王 超
昆明医学院第二附属医院泌尿科，云南省昆明市 650101
詹 辉☆，男，1977年生，云南省保山市人，汉族，昆明医学院在读博士，主要从事膀胱癌的诊断及治疗。
通讯作者：王剑松，昆明医学院第二附属医院泌尿科，云南省昆明市 650101
摘要
背景：长期随访结果发现，原位回肠尿流改道再造膀胱方法可致酸碱平衡及营养代谢障碍，另外回肠位置较高，必须有较长的系膜方可使膀胱位于盆腔且与尿道吻合处的张力不致过高。而乙状结肠位置靠近尿道，且原位乙状结肠尿流改道再造膀胱具有对电解质酸碱平衡及营养代谢影响较小，分泌黏液较少等特点。
目的：采用长期随访形式比较膀胱癌患者采用回肠和乙状结肠再造膀胱的优劣。
设计：回顾性分析。
单位：昆明医学院第二附属医院泌尿外科。
对象：选择1995-01/2005-03昆明医学院第二附属医院泌尿外科住院的膀胱癌患者164例。行原位回肠尿流改道再造膀胱96例（回肠组），男74例，女22例，年龄43~74岁；行原位乙状结肠尿流改道再造膀胱68例（乙状结肠组），男64例，女4例，年龄51~72岁。所有患者均经病理检查确诊；患者及家属均对治疗方案知情同意。治疗方案经医院伦理委员会批准。
方法：①原位回肠尿流改道再造膀胱：膀胱全切后,距回盲瓣15~20 cm处截取40~60 cm长带蒂回肠袢制作储尿囊，双侧输尿管吻合于两端预留肠管，储尿囊最低部与尿道残端吻合。②原位乙状结肠尿流改道再造膀胱：膀胱全切后，截取30~40 cm长带蒂乙状结肠制作储尿囊。双侧输尿管同上法吻合于近端预留肠管。
主要观察指标：观察手术时间、术中失血量、下床活动时间、术后留置单J管及尿管时间。以定期复诊的方式进行随访，观察患者控尿排尿能力、尿动力学分析结果以及术后早期与晚期膀胱相关并发症。
结果：164例患者失访12例（7.3%）。回肠组平均随访46个月，乙状结肠组为42个月。两组术中失血量、术后控尿效果相近（P >0.05），原位回肠尿流改道组手术耗时较长，术后恢复较慢，新膀胱容量较大(t =2.56~3.08,P < 0.05~0.01)。原位回肠尿流改道组术后早期及晚期膀胱相关并发症发生率分别为16.7%，29.2%，均高于乙状结肠组(9%,16%)，其中晚期并发症发生率比较，差异有显著性意义（χ2 = 5.426,P < 0.05）。
结论：原位乙状结肠尿流改道再造膀胱耗时短、恢复快、术后并发症发生率低。
关键词：再造膀胱；原位尿流改道术；回肠代膀胱；乙状结肠代膀胱；组织构建；再生医学
中图分类号: R617 文献标识码: A 文章编号: 1673-8225(2008)05-00983-04
詹辉, 王剑松, 徐鸿毅, 石永福, 左毅刚, 杨德林, 王超.原位回肠与乙状结肠尿流改道再造膀胱：10年资料回顾[J].中国组织工程研究与临床康复，2008，12(5):988-991
[www.zglckf.com/zglckf/ejournal/upfiles/08-5/5k-988(ps).pdf]
(Edited by Shen H/Ji H/Wang L)