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Dr. Joseph Smith Jr. holds an illustration of the artificial bladder created through a new type of surgical procedure. (photo by Dana Johnson)

Procedure creates new bladder from patients' own intestines

BY: BARB CRAMER

4/21/2000 - A new surgical procedure at Vanderbilt University Medical Center is helping bladder cancer patients to regain normal urine function more quickly and avoid uncomfortable and awkward urine collection systems.

Dr. Joseph A. Smith, Jr., William L. Bray Professor of Urologic Surgery and Chair of Urology, helped develop the orthotopic neobladder procedure, which involves reshaping a portion of the small intestines to create a new receptacle to replace a diseased bladder. A study of the procedure's effectiveness was recently published in the Journal of Urology.

"We studied 100 patients who had the neobladder surgery. There were no deaths and all the patients regained good daytime urinary control. None required protective pads during the day and only 18 percent used protective padding at night because of nocturnal leakage," Smith said.

"We are very proud of our results. Not a single patient died and that is good, because around the country there is about a 5-10 percent mortality rate with surgery for bladder removal. We have done more than 300 with no mortality."

Most patients undergo bladder removal because of bladder cancer, but Smith says the operation is also done on patients who have suffered bladder trauma or spinal cord injuries.

In the past, a patient's bladder was removed and a small hole was created to accommodate a urine collection bag.

"That surgery still works well and is still recommended for some patients, but most people don't want that," Smith said. "Now we can offer an alternative — an artificial bladder or a new bladder.

With the neobladder surgery, doctors take a part of the patient's small intestines — about 35-40 inches — and mold it into a spherical, grapefruit-size shape. This newly formed 'bladder' is then connected to the kidneys and the urethra. Following recovery, urination is usually normal.

"This is a normal intestine that we are using," Smith said. "It is a couple of inches in diameter and we separate it from the normal intestinal flow and then sew the intestine back together again, so that the bowel function is not impaired.

"Once it is connected to the ureters and the kidneys, the urine comes from the kidneys, empties into the neobladder and is stored in this new reservoir."

Smith says with this new bladder, all the materials are from the patient's own body, eliminating the need for antibiotics or immunosuppressive medications to fight rejection.

Smith said his department has done more than 200 neobladder surgeries during this current investigation series, one of the largest of its kind in the world. Smith, who has helped develop the procedure for the past 20 years, has performed as many as 400 neobladder procedures.

"We are pretty far ahead of the curve. While it takes most medical centers eight to 10 hours to remove the bladder and add the bag, it takes us only two-to-three hours," Smith said.

"And with the neobladder, we can do it in four-and-a-half to five hours, while it takes other medical centers 12-to-16 hours. That makes it better for our patients, because they aren't in the operating room as long."

Estimates are that 10,000 people will be diagnosed with bladder cancer this year, making it the fifth most-common cancer.

The most common symptom is blood in the urine. Other symptoms include urinary frequency problems and pain with urination.

Bladder cancer is a very aggressive cancer and tends to spread to distant sites fairly rapidly if not removed when it is still localized to the bladder wall, Smith said.

"Being able to lessen the impact of the surgery with this neobladder approach allows us to more comfortably recommend it to people," Smith said. "With this procedure, we are encouraged to recommend it sooner to patients with bladder cancer thereby avoiding the disease spreading."

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