Orthotopic neobladder in management of tubercular thimble bladders: initial experience and long-term results

To describe the indications and long-term results of orthotopic bladder replacement for tubercular thimble bladders.

Four patients (3 women, 1 man; mean age 32 years) presented with markedly contracted bladders of tubercular etiology. The patients had marked lower tract symptoms, and the mean bladder capacity was 15 mL. All 4 patients had associated upper tract pathology. Four-drug antitubercular treatment (ATT) was started in all 4 patients, and all 4 underwent surgery 4 weeks later. The procedure performed was a cystectomy and orthotopic bladder reconstruction using the ileocecal segment in 3 patients and the sigmoid colon in 1. The ureters were implanted into the taenia of the cecum or the sigmoid in an antireflux fashion. ATT was continued for a total of 9 months.

All patients had an uneventful postoperative course. After a follow-up period ranging from 22 to 54 months (mean 38), the average bladder capacity in the 4 patients was 450 mL (range 400 to 600). The mean maximal flow rate was 18.3 mL/s. Potency was preserved in the man and all patients were continent at last follow-up. The male patient had hypercontinence requiring clean intermittent catheterization for a period of 3 months. At last follow-up all patients had residual-free micturition. The female patients were able to void to completion with a Valsalva maneuver. No patient had symptomatic urinary infection or deterioration in renal function. No patient had persistent ureteral reflux or stricture.

Cystectomy with orthotopic bladder replacement offers an alternative to the urologist treating end-stage tubercular bladders (thimble bladders) with a capacity of less than 15 to 20 mL. This treatment removes the source of the symptoms, permits anastomosis to healthy tissue of the proximal urethra, and addresses lower ureteral pathology at the same time. The long-term results in these initial cases are encouraging; however, only a prospective, randomized trial can establish whether these advantages actually translate into long-term clinical benefit in this group of patients.