肠代膀胱术中输尿管吻合方法的改进

目的：探讨肠代膀胱输尿管吻合的理想方法。方法：对60例肠代膀胱术后118侧作肠代膀胱输尿管吻合的患者进行随访．对不同吻合方法的效果作对比分析。采用黏膜下隧道法吻合6例11侧，黏膜沟法吻合10例19侧，改良黏膜沟法吻合42例84侧．改良乳头种植法吻合2例4侧。结果：吻合一侧所需时间．黏膜下隧道法和黏膜沟法为25min，改良黏膜沟法8min，改良乳头种植法5min。无吻合口漏及输尿管反流并发症，吻合口狭窄均见于黏膜下隧道法。结论：改良黏膜沟法和直接种植法是肠代膀胱输尿管吻合的理想方法。     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

Wallace direct versus anti-reflux Le Duc ureteroileal anastomosis: comparative analysis in modified Studer orthotopic neobladder reconstruction

Objectives: To investigate and compare Wallace direct ureteroileal anastomosis with Le Duc anti‐reflux procedure in modified Studer orthotopic neobladder reconstruction after radical cystectomy. Methods: A total of 72 consecutive patients who underwent modified Studer orthotopic bladder reconstruction after a radical cystectomy for bladder cancer were investigated. They were examined for vesicoureteral reflux, hydronephrosis, and pyelonephritis at 6 months after surgery according to the type of ureteroileal anastomosis. Results: Vesicoureteral reflux occurred in 29 ureters (38.2%) after the Wallace procedure compared to six ureters (9.6%) with the Le Duc (P < 0.05). Hydronephrosis was detected in 12 ureters (18.8%) in the Le Duc patients compared to seven (9%) in the Wallace patients (P > 0.05). Six months after the operation, all three patients with vesicoureteral reflux‐related hydronephrosis improved using clean intermittent catheterization in the Le Duc patients; five of seven patients were cured by clean intermittent catheterization and two improved without any treatment in the Wallace patients. Seven of nine cases of ureteroileal anastomosis stenosis causing hydronephrosis were cured without any treatment but one case resulted in a non‐functional kidney despite treatment of the stenosis. Conclusions: Direct ureteroileal anastomosis using the Wallace method is effective for minimizing ureteroileal anastomosis stenosis and it represents a simple surgical procedure when combined with a modified Studer procedure.     

Does the Success of Ureterointestinal Implantation in Orthotopic Bladder Substitution Depend More on Surgeon Level of Experience or Choice of Technique?

Purpose

We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience.

Materials and Methods

A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months.

Results

There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant.

Conclusions

The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.     

Experience and functional outcome of modified ileal neobladder in 95 patients

AIMS: We took advantage of the Goodwin method to develop a modified ileal neobladder. We present the operation procedure and assessed the functional results. METHODS: From April 1997 and May 2005, 95 patients (75 men and 20 women), mean age 64.6 years (range: 36-80 years) underwent orthotopic ileal neobladder replacement with application of the Goodwin method. The Le Duc technique was used for antireflux procedure. However, for the last 35 patients, antireflux procedure was not carried out. The median follow-up period was 37 months (range: 3-98 months). We reviewed the surgical outcome and complications. Continent status and urodynamic profile were also measured. RESULTS: The mean operation time for the neobladder formation was 130 mins (range: 65-285 mins). There were no perioperative deaths. Leakage from the ileourethral anastomosis leak was found in four patients (4.2%), wound infection in nine patients (9.5%), ileal anastomosis leak in two patients (2.1%) and paralytic ileus in two patients. No hydronephrosis, neobladder-ureteral reflux or deterioration of renal function was seen. The maximum neobladder pressure was 21 +/- 13 cm (mean +/- SD) at 6 months and 12 +/- 11 cm at 12 months after surgery. The neobladder capacity was 293 +/- 118 mL at 6 months and 312 +/- 85 mL at 12 months after surgery. Of the 95 patients, 87 (91.6%) maintained complete dryness day and night. CONCLUSIONS: These results suggest that the present orthotopic ileal neobladder is simple to be carried out and achieves acceptable voiding function. Longer observation for neobladder and upper urinary tract function is necessary.     

Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures.

A urethral controlled bladder substitute was constructed from a detubularized, double folded ileal segment in 40 male patients following cystoprostatectomy for bladder cancer. For reflux prevention patients were prospectively randomized to receive either an intussuscepted nipple valve or the ureters were implanted by the Le Duc mucosal trough technique. All patients had normal upper tracts preoperatively. Mean patient age, performance status and stage of cancer were comparable in both groups. Patients were evaluated 6 to 18 months postoperatively. In addition to history taking, assessment included excretory urography, ascending cystography and voiding cystourethrography. During the observation period all patients with nipple valves had normal radiographic appearance of the upper tracts without evidence of reflux. On the other hand, following the Le Duc procedure 12 of 38 renal units (31%) showed evidence of radiographic dilatation. Of the 12 units 11 had stenotic ureters and 1 had reflux. We conclude that nipple valves are more effective in reflux prevention and protection of the upper urinary tract in patients for whom an ileal neobladder is indicated.     

Modified Ghoneim's technique using a single serous-lined extramural tunnel in detubularized orthotopic ileal W-bladder

OBJECTIVES: We report our preliminary clinical experience with a modification of Ghoneim's original technique involving reimplantation of ureters in a single tunnel on the right part of the neobladder forming a 'W' shape. METHODS: From 1997 to 1999, we performed radical cystectomy with double 'W' orthotopic neobladder construction and uretero-ileal reimplantation using our modified Ghoneim's technique on 11 male patients, aged 40-74 (mean 65.5) years, affected by invasive bladder cancer. RESULTS: No postoperative complications were observed. After a mean follow-up of 12.5 months all patients are free of recurrences. CONCLUSIONS: In our hands the modified Ghoneim's technique seems to reduce the mean operating time required to tailor the uretero-ileal anastomosis and guarantee greater stability of the anastomosis itself.     

A deserosalized muscle layer covering method for antireflux ureteroileostomy: a preliminary clinical trial

PURPOSE: To achieve complete protection of the upper urinary tract in patients with a neobladder we designed and clinically applied the deserosalized muscle layer covering method, a new antireflux ureteroileal reimplantation technique in which the terminal ureter is implanted in the muscle layer of the ileum. We present the operative procedure and preliminary results. MATERIALS AND METHODS: We created an orthotopic ileal neobladder after radical cystectomy in 5 patients with invasive bladder cancer. The ureters were reimplanted into the reservoir using the deserosalized muscle layer covering method. The functional outcome of this procedure was evaluated by radiological studies. RESULTS: No patients died during the perioperative period and no reimplanted ureters showed ureteral reflux or ureteral stricture during the observation period. Video cystometrograms demonstrated the complete prevention of reflux during the voiding and storage phases. CONCLUSIONS: The deserosalized muscle layer covering method provided a nonobstructed unidirectional flow of urine in all renal units examined in this study. The efficacy of this method was proved during short-term followup.     

A Simplified Method of Ureteral Implantation into the Orthotopic Ileal Neobladder

Purpose: A simple non antireflux technique is described for ureteral implantation in to the orthotopic ileal neobladder. Materials and methods: Forty-nine ureteroileal anastomoses into the orthotopic ileal neobladder were performed on 25 adult male patients undergoing radical cystectomy and bladder substitution. The operative technique is described in detail. Results: Surgery-related complications were found to be 3 cases of ureteral dilatation. The cause was anastomotic obstruction (stricture) in one of the cases, and ureteric angulation and periureteritis on the middle third, in two of the cases. None of the patients showed signs of reflux be means of neocystography. Conclusion: Ileal neobladder as low pressure bladder substitute does not require antireflux manoeuvering on ureteral implantation. The technique of the method described is very easy to perform. Long-term follow-up of a larger number of patients is indicated.     

Ureteroenteric anastomosis in continent urinary diversion: long-term results and complications of direct versus nonrefluxing techniques

PURPOSE: Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion. MATERIALS AND METHODS: Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months. RESULTS: Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia. CONCLUSIONS: Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.     

Double-J ureteral stents: an alternative to external urinary stents in orthotopic bladder substitution.

OBJECTIVE: The aim of this study was to compare advantages and disadvantages of using double-J or external stents to preserve the uretero-ileal anastomosis in patients receiving an orthotopic neobladder. METHODS: 77 consecutive patients with bladder cancer who underwent radical cystoprostatectomy and Studer neobladder were evaluated. All patients received a direct spatulated end-to-side uretero-ileal anastomosis in the afferent loop (Nesbit technique). In 45 patients (group A), the stents (Bracci ureteral splint) were brought our through the reservoir and anchored to the skin; in 32 patients (group B), an internal double-J stent was used. Median follow-up was 30 months. RESULTS: 9 (11.5%) uretero-ileal anastomosis strictures in group A and 7 (11.6%) in group B were observed. There was a significant difference in the side of stricture with a greater prevalence on the left side (p<0.004). Stricture formation and side were not related to the type of stent used. 14 (20%) neobladder-ureteral refluxes occurred, with a non-significant difference between the two groups (p = 0.37). 12 patients (86%) were asymptomatic; two patients developed pyelonephritis and needed antibiotic treatment. Neobladder catheter was removed after 17 days (range: 15-18 days) and 14 days (range: 12-15 days), respectively, in group A and group B with an earlier discharge of the patients in group B. There was a significant difference in mean hospital stay between the two groups (Mann-Whitney test p<0.0001). Discomfort related to the stent was mild for most of the patients of group B (84%). CONCLUSIONS: Internal stenting is an equally effective alternative to external stent in patients undergoing bladder replacement. The use of double-j stents appears to be associated with minimal discomfort, earlier mobilization and a shorter hospital stay.     

Covering of the terminal ureter with de-serosalized muscle layer of the ileum for antireflux ureteroileostomy: an experimental study in dogs and a preliminary clinical trial

We demonstrated a new operative technique for antireflux ureteroileostomy in dogs. The severed ureter was reimplanted into the isolated ileum. Ten terminal ureters were covered with a 2 x 2 cm2 section of de-serosalized ileal wall after direct ureteroileostomy, and another six terminal ureters were covered with a 2 x 2 cm2 section of non-de-serosalized full-thickness ileal wall. Thirteen ureters were directly anastomosed to the ileum without any additional procedures. The bladder was augmented by the detubularized ileum with the ureter. Postoperative evaluations on ureteral stenosis and reflux were performed monthly for 3 months. The ureters covered with the de-serosalized ileal wall prevented ureteral reflux even when the intravesical pressure climbed as high as 100 cm H2O. Although two of these ten ureters demonstrated strictures at the precise site of direct ureteroileostomy, the sections of the ureters covered with the de-serosalized ileal wall were opened and did not collapse. In the resected specimens, the terminal ureters were found in the intramural part of the ileum. The ureters covered with the full-thickness of ileal wall did not prevent reflux. Our method of covering the terminal ureter with the de-serosalized ileal wall worked well as an antireflux mechanism, and the intramural ureter did not cause ureteral stricture. After this animal experiment, we introduced this antireflux mechanism clinically.     

Le Duc-Camey antireflux ureteroileal reimplantation for continent ileal reservoir]

Le Duc-Camey antireflux ureteroileal reimplantation was used on 15 patients with 30 ureters reimplanted into the ileum as part of a bladder substitution procedure (Kock pouch or ileal neobladder: U-bladder) or augmentation cystoplasty (Goodwin ileocystoplasty). In our experience, no reflux was observed, while hydronephrosis was identified in one ureter of ileal neobladder (4%). Le Duc-Camey antireflux ureteroileal reimplantation is suitable for reconstruction with the ileal reservoir.     

Ureteral stenosis of uretero-ileal anastomosis

Replacement plasty allows to perform oncology surgery while maintaining body image and preserving renal function. Entero-ureteral anastomosis is a significant element in this procedure where the main responsible for the loss of renal function are stenosis, infection and reflux. Our group has performed 206 orthotopical vesical replacements (November 1981-November 1998), using a direct Wallace-type uretero-ileal anastomosis. An intussusception valve system was used as antireflux mechanism. The number of obstructions, rate of stenosis at the uretero-ileal junction and incidence of valve stenosis were all analyzed as part of the complications occurred over a follow-up period of 54 months (6-183). Findings included 6 stenosis at the uretero-intestinal junction and 2 at the intussusception valve. Two (3.8%) of the uretero-ileal stenosis were earlier and associated to fistula; one was treated with open surgery and one had a double J placed through antegrade percutaneous access. Of the remaining late four, only one was treated with a double J catheter while the other three had to be re-operated. Stenoses of the valvular system (1.2%) were solved with open surgery. From our experience, we believe that direct uretero-ileal implantation with scraping of the ureter is a safe technique with little risk for stenosis at the uretero-ileal junction. Intussusception was used a antireflux system in all cases.     

De-serosalized muscle layer covering method for antireflux ureteroileostomy: a new operative technique and pressure study with ureterometry at the ureteroileal anastomotic site in dogs

PURPOSE: In pursuit of a more effective antireflux ureteroileostomy with a lower postoperative complication rate we performed a new operative technique and evaluated intraureteral pressure with ureterometry to examine the mechanism of antireflux function. MATERIALS AND METHODS: A total of 11 beagle dogs were used in this study. A 3 x 2 cm. section of the ileal serosa was removed, the severed ureter was directly anastomosed to the de-serosalized area and 1 cm. of terminal ureter and the direct anastomotic site were covered with the de-serosalized ileal wall. The bladder was augmented with the ileum containing the ureter. Postoperative evaluations were performed monthly and ureterometry of the reimplanted ureter was done 6 months postoperatively. RESULTS: Complete reflux prevention and a low stricture rate were achieved with this procedure. Direct ureteroileal anastomosis caused stricture in 1 of the 11 ureters but the covering procedure to prevent ureteral reflux caused no ureteral strictures. When the bladder was empty, ureteral closure pressure at the intramural portion of the ureter was low. At the phase of high intravesical pressure ureteral closure pressure at the intramural ureter was as high as intravesical pressure. CONCLUSIONS: The de-serosalized muscle layer covering method prevented ureteral reflux completely with a low stricture rate. The antireflux function of this method seems to depend on the flexibility of the terminal ureter covered with the de-serosalized ileal wall. Reflux prevention in the low intravesical pressure phase seems to be due to extension of the ileal wall.     

Upper urinary tract dilation due to conglutination of intraluminal distal ureters after orthotopic neobladder with split-cuff nipple ureteral reimplants: Early results of 8 cases

ObjectiveWe reviewed our experience with dilation of the upper urinary tract caused by the conglutination of distal ureters after orthotopic neobladder reconstruction using the split-cuff nipple ureteral reimplant technique.Materials and methodsFrom January 2000 to April 2007, 250 consecutive patients underwent radical cystectomy and orthotopic neobladder reconstruction. Ureterointestinal anastomosis was performed using the split-cuff nipple technique in 291 renoureteral units. The patients from a single center were followed up for a mean period of 8 months (range 1–22) after surgery. We incised the conglutination band using a transurethral endoscope. Patient characteristics, endoscopic technique, measurement of serum creatinine levels, and results of ultrasonography, cystoscopy, and excretory urography were collected.ResultsHydronephrosis was found in 8 patients (14 renoureteral units) due to the conglutination of the distal ureters to each other (n = 6) or to the neobladder wall (n = 2). After the incision procedure, seven patients had obvious improvement in renal function and hydronephrosis, and their symptoms disappeared. In 1 patient, hydronephrosis developed again because of ureteroenteric stenosis after 7 months and was resolved by open surgical revision. The hydronephrosis had improved greatly in this patient by 5 months after revision.ConclusionConglutination of the distal ureters is a cause of hydronephrosis after orthotopic neobladder reconstruction using the reimplant technique with the split-cuff nipple. Cystoscopy is mandatory in following up patients who have hydronephrosis with the split-cuff nipple ureteral reimplant technique, not only to confirm the diagnosis but to treat the complication by incising the conglutination band. Continued follow-up is required to evaluate the long-term results of this treatment.     

可控性尿流改道的输尿管肠管吻合术式的比较

目的　比较输尿管肠管的直接吻合和黏膜隧道式、袖口乳头式抗返流吻合术式的并发症发生率 ,为临床术式的选择提供指导。　方法　 6 3例可控性尿流改道术 ,其中 2 4例采用输尿管肠管直接吻合术 (直接吻合组 ) ,39例采用抗返流吻合术 (抗返流吻合组 )。比较直接吻合组和抗返流吻合组术后吻合口狭窄、输尿管返流、肾功能损害及尿路感染等并发症的发生率。术后随访时间 3个月至 6年 ,平均 2 6个月。　结果　 78条输尿管肠管抗返流吻合者 ,术后 12条输尿管出现吻合口狭窄。而直接吻合组 4 8条输尿管仅 1条出现吻合口狭窄 ,两者差异有显著性 (χ2 =4 375 ,P <0 0 5 )。抗返流吻合组和直接吻合组术后输尿管返流、肾功能损害及急性尿路感染发生率差异无显著性。结论　黏膜隧道式、袖口乳头式抗返流吻合术后输尿管吻合口狭窄发生率较直接吻合术高。对可控性尿流改道的输尿管肠管吻合宜选择直接吻合术。     

浆膜间隧道技术在尿路重建中的临床应用

目的 评价浆膜问隧道技术在原位膀胱、可控尿流改道和回肠代输尿管成形术中的临床应用效果. 方法浆膜间隧道技术是将重建输出道或再植输尿管置于储尿囊的回肠壁浆膜之间以达到可控或者抗反流的目的 .应用浆膜间隧道技术在原位回肠膀胱重建患者中行输尿管再植31例,可控回肠膀胱重建患者中行可控瓣成形和输尿管再植13例,回肠代输尿管成形患者中在输尿管近端应用该技术抗反流3例. 结果平均随访27(12～132)个月.88根植入回肠新膀胱或可控膀胱的输尿管功能良好,造影显示无梗阻或反流,13例可控瓣12例无漏尿,3例回肠输尿管成形患者造影均无回肠输尿管反流,IVU显示肾积水较前明显好转. 结论应用浆膜问隧道技术进行输尿管再植和可控瓣成形临床效果良好,可以作为尿路重建中的常规应用.     

The "B-bladder"-an ileocolonic neobladder with a chimney: surgical technique and long-term results

OBJECTIVES: A modified version of the "Le Bag" ileocolonic neobladder with a "Studer"-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described. METHODS: Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years. RESULTS: The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months. CONCLUSIONS: The B-bladder maintains the simplicity of preparation of the original "Le-Bag" neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent.     

The ileal neobladder

Currently we are witnessing an increase of interest in bladder substitution enterocystoplasty. The goal of this presentation is to describe operative technique and first clinical results of a ileal neobladder for total bladder replacement. Creation of a ileal neobladder for total bladder replacement is described in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressures lower than 30 cm water and no reflux. Eight of the 11 patients with the neobladder are completely dry day and night. Three are stress incontinent grade I. All 11 patients developed recognizable sensations of bladder distension closely simulating those of their earlier bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers a stoma free alternative to urinary diversion resulting in a highly compliant low pressure bladder. A urodynamic comparison between the most recent developments (Kock-pouch, Camey, Mainz-pouch, "Le Bag") is made and this clearly shows the ileal neobladder to have several distinct advantages: the ileocolonic junction and the terminal ileum are saved; the operative technique is safe, simple and reliable (no Kock valve, no 180 degree rotation of the reservoir, simple antireflux technique); development of recognizable sensations of bladder filling in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)