Neobladder and Pelvic Rehab

Among the patients who we serve, the diagnosis of orthotopic neobladder, or "neobladder" can leave the pelvic rehab therapist wondering about the procedure itself as well as the best course of therapy. Understanding the anatomy and physiology of the surgical diversion, the risks and benefits, and the common urinary dysfunctions can assist in development of the plan of care.The neobladder surgery is one option for patients who must have the bladder removed, often in the event of bladder cancer. As the 4th most common cancer in the United States, theNational Cancer Instituteestimates that there will be over 72,000 new cases of bladder cancer in the US in 2013. Other reasons a patient may be a candidate for a neobladder surgery include a neurogenic bladder that risks renal function, radiation injury to the bladder, severe urinary incontinence, and pelvic pain syndromes.

The surgery involves creating a pouch for storage of urine from a portion of the small intestine. For a brief and helpful video of how this surgery is completed, click here. Early complications of the surgery include rupture of the new bladder reservoir and bacterial peritoneal infection. This is a medical emergency and would be treated with antibiotics and surgical revision. Late complications can include urinary obstruction. More commonly, patients who are referred for pelvic rehabilitation may experiencedysfunctions including urinary incontinence and retention. While the latter tends to be an issue in the immediate post-surgical period, incontinence is more prevalent in later recovery. A Medscape article about urinary diversions and neobladder can be accessed here.

An article reviewing 1000 cases of neobladder surgery over 25 years reports complications including hydronephrosis, incisional hernia, ileus or small bowel obstruction, urinary tract infection, B12 deficiency, and occasional obstruction and even death. The authors conclude that patient age and comorbidities contribute to the challenge of avoiding such complications, and that patients are best managed in a surgical center where many of the operations are completed. In another article describing the urinary function outcomes in 49 women who were treated with a neobladder diversion, daytime incontinence was reported in 43%, nightime incontinence in 55%, and hypercontinence in 31%. Hypercontinence refers to difficulty emptying the neobladder. Aweb postingon a site for survivors of bladder cancer describes a technique that women can use to aid in emptying the pouch.

A review of websites and journal articles describing postoperative interventions typically lists "Kegel exercises" as one part of training. Further research will assist in providing recommendations for treatment, yet at this time, patients will be able to benefit from standard therapy approaches for urinary dysfunction. Behavioral training can help the new pouch stretch to some extent, the patient may need to learn to relax the pelvic floor while using low level abdominal pressure to empty the bladder, and information about proper hydration will also be beneficial. Because the lining of the neobladder is mucosal, it sloughs off bits of tissue that appear in the urine as a normal part of postoperative voiding. This fact increases the importance of maintaining a hydrated level of fluid in the body to help pass these bits of tissue and avoid blockage. Keep in mind that many patients who present with a neobladder may have experienced other medical treatments for cancer or other disease processes or illnesses, and the effects of these other medical interventions can affect speed of recovery.

A patient who was recently referred to me for continence training following a neobladder surgery progressed to 75% improvement of stress incontinence over a period of 6- 8 weeks, with a further recovery with home program to near 90% recovery. His examination included pelvic muscle strength, coordination, and endurance assessment via the rectal canal, and his treatment plan included a progressive exercise program based on the findings of the exam. Each patient who presents to our facilities will have a varied history, and a thorough subjective exam will guide the pelvic rehab provider in determining the appropriate examination approach. There are patient resources available on the internet that also inform the rehab therapist. For example, the Bladder Cancer Advocacy Network provides this handout "for patients from patients" that highlights suggestions and common questions. If you are working in or near a large hospital system, finding out who performs these surgeries may offer an opportunity for marketing if you are not yet seeing these patients. If you are in a more rural location, you may find that a patient living in your community can complete follow-up in your clinic while attending medical appointments with the surgeon as needed.