Improving Conduit and Neobladder Efficiency: Surgical and Post-Operative Strategies

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, Dr. Mutahar Ahmed will discuss strategies for improving conduit and neobladder efficiency. Dr. Ahmed is the Director of the Center for Bladder Cancer at Hackensack University Medical Center and a Professor of Urology and the Director of the Minimal Invasive Robotic Oncology and Urology Fellowship Program at Hackensack Meridian School of Medicine. He also spoke on this topic at the American Urological Association 2025 Annual Meeting. Let’s hear from Dr. Ahmed now.

Dr. Ahmed:
The way you can increase the efficiency of the ileal conduit is to identify the segment of the bowel you will use, make sure it has a good blood supply, and mark that area. And it’s different when you do them robotically than open. When open, you can measure; you can do all this in there. Using lots of stay sutures are the key to this surgery. You only have limited sets of hands, right? When you are doing it robotically, you have one or two cameras. Then you have one, two, or three arms that you can use, whereas when you’re doing an open case, you have your assistant arms; you could have two or three assistants to helping you out. So that’s why these stay sutures are very important—you can isolate the bowel segment first and mark it out, but then these sutures also help you to manipulate the bowel. And then we will use a robotic stapler. So once you isolate the bowel, then you have to put the bowel back together so you have a continuity, and that’s where the robotic stapler really comes into handy.

How can you improve the continence after a neobladder? In males, we have prostate that is attached to the bladder. Where the prostate ends is called the apex of the prostate, and the urethra starts, and about a centimeter or two away from that is the main sphincter, and you want to preserve that sphincter. When you do that intraop, that’s a very important step, preserving that sphincter. Preservation of the apical part of the prostate, preservation of that sphincteric muscle, preservation of the levator muscle, and striated muscle of the sphincter—all these things help to preserve the continence.

On a female patient, it’s very important during the surgery that you must preserve the anterior vagina—especially the distal part of the anterior vagina—because in their case, anatomically, the urethra is much shorter. If you are not able to do that, you should not do a neobladder. Do a conduit. You could do an Indiana Pouch or continent pouch, so intraoperative, preserving that anterior distal vagina. Teach them how to do Kegels and have postoperative physical therapy for pelvic floor as well. So with that, you can improve the continence rate.

Most of these cystectomies are done for bladder cancer or urothelial cancer. You’ll do routine follow-up for that. If they have an oncologist, they may do additional tests as well. Generally, they involve repeating a CAT scan, ultrasound, and blood test. There are many support groups. I actually have patients who have gone on YouTube to talk about it so the patient feels at ease.

The neobladder, because it’s not a bladder of your own, it doesn’t have a contractility, so they have to learn how to use the abdominal muscle to get this thing empty. Some people find it easier when they sit so they can put a pressure on their abdominal muscle, and some people find it is easier when they’re standing, so we teach them that they should learn how to understand their body and see which method works better for them. But it is not like your natural bladder where you can just go and squeeze that bladder and urine comes out. It requires a little bit of a lesson and learning process.

Announcer:
That was Dr. Mutahar Ahmed discussing tactics for improving conduit and neobladder efficiency. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!