ABSTRACT
Orthotopic reconstruction is absolutely contraindicated in all patients who are candidates for simultaneous urethrectomy, based on their primary tumor. The number of relative contraindications and comorbidity is steadily decreasing. However, some of them, such as mental impairment, external sphincter dysfunction, or recurrent urethral strictures, deserve serious consideration.1,2
The key factor in determining which patients should be candidates for a neobladder is the patient’s desire. The patient needs a certain motivation to tolerate the initial and sometimes lasting inconvenience of nocturnal incontinence associated with a neobladder. Most patients accept some degree of nocturnal incontinence for the benefit of avoiding an external appliance, but not all patients do, and realistic expectations of the functional outcome are essential. The psychological damage and stigma experienced by a patient who enters surgery expecting a neobladder, but awakens with a stoma, are increasingly recognized.1,2
There are patients who are better served with a conduit than a neobladder. The following factors are against a neobladder:
(1) The patient’s main motivation is to ‘get out of the hospital as soon as possible’ and resume normal, rather sedentary activities. Many frail patients undergoing cystectomy will have less disruption of normal activities with a well-functioning conduit than an orthotopic reservoir associated with less than ideal continence.
