الفهرس 
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Abstract
Bladder cancer is the 7th most common diagnosed cancer in male population worldwide, but it drops to 11th when both genders are considered. The worldwide age-standardised incidence rate (per 100, 000 person/years) is 9.0 for men and 2.2 for women. In the European Union, the age-standardised incidence rate is 19.1 for men and 4.0 for women
Radical cystectomy with pelvic lymphadenectomy is the standard treatment for muscle-invasive bladder cancer (stage T2 and above). Recent interest in patients’ quality of life (QoL) has promoted the trend toward bladder-preserving treatment modalities. Performance status (PS) and age influence the choice of primary therapy, as well as the type of urinary diversion, with cystectomy being reserved for younger patients without concomitant disease and with a better PS.
A comprehensible discussion with the patient about all options for urinary diversion as well as the potential short- and long-term risks and the beneficial effects of each type of diversion is mandatory for improved postoperative compliance and functional outcomes.
Controversy remains regarding age, radical cystectomy and the type of urinary diversion.. It is particularly important to evaluate the function and QoL of elderly patients using a standardised geriatric assessment, as well as carrying out a standard medical evaluation.
In several large centres, orthotopic neobladder substitution is now considered the diversion of choice for the majority of patients, both male and female, undergoing radical cystectomy and is the procedure with which all other types of diversion must be compared. Diagnosis of urethral tumour before cystectomy or positive urethral frozen section leads to urethrectomy and therefore excludes neobladder reconstruction. When there are positive lymph nodes, orthotopic neobladder can nevertheless be considered in the case of N1 involvement (metastasis in a single node in the true pelvis) but not for N2 or N3 tumors.
After urinary diversion close follow up to the patient help to detect early and late complications and give us the chance to manage any of these complications. Apart from oncological surveillance, patients submitted for urinary diversion deserve functional follow-up. Complications related to urinary diversion are detected in 45% of patients during the first five years follow-up. This rate increases over time, and exceeds 54% after fifteen years follow-up. Therefore, long-term follow-up of functional outcomes is desirable and may stop after fifteen years.
All types of neobladder construction are based on the concept of detubularization and folding to provide adequate-sized spherical reservoir with low pressure reservoir. The terminal ileum possesses superior anatomic and functional characteristics. Superiority of one neobladder technique over others, still exist as regarding the technique of preventing reflux in orthotopic substitutes and improving continence and voiding pattern.
Uretho-ileal anastomosis were facilitated by making a buttonhole in the most dependent portion of the pouch close to the urethral stump or proximal 2 cm of the ileum were nondetubularized and anastomosed to the urethra eating or leaving a small opening in most dependant part of the anterior suture line.
Emptying of the reservoir anastomosed to the urethra requires abdominal straining, intestinal peristalsis, and sphincter relaxation. However, analysis of studies reveals rates of dysfunctional voiding of 0–20% and 9.0–21.2% for a 40–50 cm and 60 cm ileal segment, respectively. Therefore, it is believed that it is more important to instruct the patient to empty the neobladder on a regular basis to avoid the development of a floppy bag. The etiology of urinary retention has been debated, but most authors believe it is due to fall of pouch into the pelvic cavity resulting in a mechanical kink in the urethra–reservoir anastomosis. Other suggested etiologies include autonomic denervation of the urethral remnant, elongation of the neobladder neck and position of neobladder neck not at the lowest portion of pouch.
Daytime continence rates in U-pouch vary from 21.4% to 99.0% at 3–48 months postoperatively. The W pouch, a commonly used technique, recorded a daytime continence rate of 93.3%. Particular attention should be directed toward preserving the rhabdosphincter in order to protect the continence mechanism. Treatment options for those with persisting severe incontinence may include pharmacotherapy, a urethral sling or an artificial urinary sphincter.
In our study, urethral lengthening using dependent part of reservior is promising alternative as regard continence (83.3%-90% of patients are continent at daytime and 46%- 53% are continent at nighttime) provided that instructing the patient to empty the neobladder on a regular basis. Patients had adequate voiding pattern (mean of maximum flow rate was ranging from 12.2ml/sec to 13.3ml/sec). So that, tubularized flap from ileal pouch allows coming over some anatomical difficulties during operation such as short urethral or deep pelvis and provides also well coaptted urethro-ileal anastomosis in a tension free manner with adequate diameter of its lumen.
Laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) were considered as investigational procedures for which no advantages could be shown as compared to open surgery. RARC provides longer operative time (1-1.5 hours), major costs; but shorter length of hospital stay (LOS) (1-1.5 days) and less blood loss compared to open radical cystectomy (ORC). Surgeons experience and institutional volume are considered the key factor for outcome of both RARC and ORC, not the technique. The use of neobladder after RARC still seems under-utilised, and functional results of intracorporeally constructed neobladders should be studied.