Pro & cons of Neobaldders vs stoma

[Peter__0__0]

  I am due to have my bladder removed and my Urologist is trying to get me to decide on either a stoma/bag or a neobladder, which needs self decatheterization.
  I have spoken to people with bags, but not with neobladders and have little information about them.
  Questions:
  -Is the risk of infection higher with a neobladder.
  -Do any/some/what % people return to some level of continence
  -Can you feel when it is full/what happens if you don't drain it.
   Is there any risk of leakage with physical activity, eg kayaking
  - How feasible is it to change from a neobladder to a stoma
   later if you don't like it.
  -Any comments from anyone who has had the same decision.
  -Any other useful comments, to assist me to decide.
  Thanks, Peter
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Dear Peter,
Cystectomy (bladder removal) remains the most effective means of curing invasive transitional cell carcinoma of the bladder. Prior to cystectomy  the patient and physician must decide between a continent reservoir (neobladder) and the traditional intestinal conduit (bag).  Both methods are effective and each has   positives and negatives.  In fact, not everyone is a candidate for a continent reservoir.  The frequency of neobladders has risen significantly over the last ten years.  Currently, less than 50% of the patients at major urologic centers undergo traditional ileal conduits.  This is due to the improvement in the neobladder operation and the desire of patients to maintain a normal body image.
The contraindications to an ileal neobladder that attaches to the urethra are: a patient with mental or physical disability, noncompliant patient, elevated serum creatinine(>2.5), chronic inflammatory bowel disease, transitional cell cancer of the prostate or invasion of the prostate.  Other relative contraindications include: pelvic radiation in high doses, age over 70, tumor of bladder neck, and multifocal carcinoma in situ.
In regards to your question about continence, 67% of patients achieve continence by 6 months, 90% in 4 years.  Just like women with full bladders that leak when they cough or sneeze, stress incontinence will become an issue, but with proper maintenance it can be managed.
You should also know that there are more than one type of neobladder.  There are those that hook-up to your native urethra, those that have a cutaneous abdominal stoma, and those that empty into the rectum.  The first two that I mentioned are primarily used today and there are different segments of bowel used to make each type of neobladder.
The principle complications of the ileal conduit are peristomal inflammation, peristomal hernia, stomal stenosis, urinary tract stone disease, ureteroileal anastamotic stricture (narrowing of the junction between the ureter and its junction with the neobladder), pyelonephritis and upper tract deterioration.  On the other hand , the principle complications of the reservoirs are leakage of urine, formation of stones, difficulty catheterizing the stoma, urinary tract infections, and ureteral reflux and  disruption of the pouch.  This may occur if a patient is noncompliant and does not empty frequently enough.  You don’t always feel like you did when your bladder was full, but you still feel pain similar to gas and abdominal pains.  Enuresis (bed wetting) also is not uncommon and occurs if the pouch becomes too full unless a patient awakens themselves at night to empty the neobladder.  Other complications that are inherent to both operations are wound infections, intestinal obstruction, hemorrhage, venous thrombosis and cardiopulmonary problems.  In fact the reoperation rate after a cystectomy is about 10%.
It is possible to refashion the neobladder and convert it to an ileal conduit. Unfortunately, invasive bladder cancer is a tough disease to have.  The best option to cure this condition is cystectomy. You are certainly approaching it properly.  I wish you luck in your decision and I hope I didn’t confuse you more. Talk to your doctor further or one of the nurses if you are not sure of your choice before you make your final decision.
This information is provided for general medical educational purposes only.  Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition.  More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword: bladder cancer, cystectomy, urinary diversion