some are against it ( 1 ) , some advocate its application for certain and specific patients ( 2 ) , and some others believe that the use of bowel has some limitations including excessive mucus production , metabolic acidosis , stone formation , infection , perforation and malignancy ( 3 ) . there are some advantages for using a pouch of stomach for cystoplasty and gastric neobladder for example : reimplantation of ureter to this segment is easer , because of its thickness . because stomach is beyond the field of radiotherapy and free of adhesion .
stomach is an organ of choice for diversion during chronic renal failure ( crf ) . in the current study we used gastric pouch for augmentation cystoplasty in transitional cell carcinoma ( tcc ) of bladder for the first time in khorasan province ( 4 ) , also benign diseases of bladder like severe contracted bladder due to tuberculosis and failed vesicovaginal fistula ( 5 ) .
in addition , cases of gastric neobladder for malignant disease for malignant of bladder were studied .
the aim of this retrospective study was to report our experience , mostly on gastric neobladder ( not gastrocystoplasty ) for benign and malignant bladder diseases , its complications , outcomes and follow - up results .
1996 , seven cases of gastric pouch were performed in the urology department of qaem educational hospital , mashhad , iran .
five cases of invasive bladder tumor , aged between 40 - 70 ( mean : 61.6 ) years were selected for radical cystectomy after performing 1 - 3 times transuretheral resection of bladder tumor ( turbt ) .
all patients underwent staging before cystectomy including turbt , histopathologic studies , bimanual exam under anesthesia , abdominal ct , chest x ray and renal and liver tests .
1 , a.a . , a 62-year - old male ; tcc of bladder , stage b2 , grade 2 .
2 , m.b . , a 62-year - old female ; tcc of bladder , stage b2 , grade 3 .
3 , m.m.k . , a 51-year - old male ; recurrent multiple papillary tumor , involving trigone and lateral walls , stage a , grade 2 ( history of repeated turbt in a short period of time ) .
4 , g.a . , a 70-year - old male with tcc of bladder , stage b2 , grade 2 .
5 , a.a.k . , a 63-year - old male with tcc of bladder , stage b2 , grade2 .
all patients underwent cystourethroscopy ( including evaluation of urethra ) and biopsy from suspicious areas was performed ; however , no in situ carcinoma was diagnosed in any case .
patients no . 6 and 7 had urinary tuberculosis ( tb ) with positive results for urine culture .
6 was a 72-year - old man who had irritative symptoms plus gross painless hematuria and nearly true urinary incontinence .
his ivp ( intra venous pyelography ) showed ureterovesical junction ( uvj ) stenosis with a severely contracted ( thimble ) bladder .
after eight weeks of anti - tb therapy because of a 1.7 mg/100 creatinine level ( normal : 0.5 - 1.5 mg/100 ) , he underwent gastric neobladder .
7 was a 40-year - old man from afghanistan with a right hydronephrotic kidney with 5% function on dmsa and grade three reflux on the left side in voiding cystourethrography ( vcug ) .
because of left hydroureteronephrosis , percutaneous nephrostomy ( pcn ) was performed on the left side .
creatinine decreased from 5.1 mg/100 ml to 4.2 mg/100 ml and nephrostography showed a left - sided stenosis .
it consisted of liquid food as well as bisacodyl , 2 tablets a day , enema at night with normal saline , plus metronidazol 2 tablets every 8 hours .
patients were npo (  nil per os  meaning nothing through mouth ) from 12 hours before the procedure and received broad spectrum antibiotics intraparentally .
routine exploration of intra - abdominal organs was performed as well as bladder mobility evaluations .
radical cystectomy was performed for patients no . 2 , 3 , 4 and 5 .
regional lymphadenectomy was performed for patients no . 2 and 3 , but for patients no . 4 and 5 ,
frozen section of a suspicious lymph node had negative results , therefore lymphadenectomy was not performed .
3 , 4 and 5 who were male , total bladder , urachus , seminal vesicles , prostatic urethra , up to the prostatic apex were removed leaving a stump from the membranous urethra .
all ureters were cut from 2 cm from the bladder , except for patient no .
1 , in whom only partial cystectomy with 2 cm free margin was performed . for patient
2 ( female case ) , anterior pelvic exenteration with hysterectomy , oopherectomy and salpingectomy were performed leaving only a partial section of vagina and urethral stump .
7 whom had a thimble bladder . by marking a triangle on the fundus of the stomach with methylene blue , a 15 cm long base ( in our first experience ) and then 20 cm long ( after the first case ) far from antrum to the fundus was selected .
gastric wedge was brought to the pelvis by passing it through the transverse mesocolon and small bowel mesentery in a straight direction ( figures 1 , 2 ) . in case
the gastric wedge was anastomosed to the bivalve bladder , after partial cystectomy . in patients
2 and 3 , the gastric pouch was anastomosed to the urethra , and then the two ureters in each case were anastomosed to the new bladder .
two 8fr feeding tubes were put into the ureters as a stent and a three way 22fr foley catheter inside the bladder ( a d.j .
because of a small flap and a short pedicle , a distal part of the flap was tubularized around a 22 three way catheter and was anastomosed to the membraneous urethra by six sutures with 2 - 0 chromic catgut . at the end of the operation
the bladder was filled with saline solution to evaluate neobladder volume and also urinary leakage .
the operation time for patients 1 to 7 were 3 , 4.52 , 5.5 , 6 , 5 , 6 and 10 hours , respectively ( mean : 325 minutes ) .
intravenous cimetidine 200 mg four times a day , was administered after the operation for 4 - 5 weeks .
ureteral catheter was removed one week after the operation , and hemovac drain one day later ( if the amount of secretion was less than 30 ml ) .
bladder irrigation was performed continuously for the first and second patients , but for patients 3 to 7 , it was stopped .
however , after getting more experience in benign conditions ( t.b . ) , bladder irrigation was stopped .
foley catheter was removed four weeks after the operation , after retrograde cystography to assess leakage .
all patients started walking from the third post - op day except patient no . 5 , who experienced a longer operation time and post - op tachyarrhythmia .
routine exploration of intra - abdominal organs was performed as well as bladder mobility evaluations .
radical cystectomy was performed for patients no . 2 , 3 , 4 and 5 .
regional lymphadenectomy was performed for patients no . 2 and 3 , but for patients no . 4 and 5 , frozen section of a suspicious lymph node had negative results , therefore lymphadenectomy was not performed .
3 , 4 and 5 who were male , total bladder , urachus , seminal vesicles , prostatic urethra , up to the prostatic apex were removed leaving a stump from the membranous urethra .
all ureters were cut from 2 cm from the bladder , except for patient no .
1 , in whom only partial cystectomy with 2 cm free margin was performed . for patient
2 ( female case ) , anterior pelvic exenteration with hysterectomy , oopherectomy and salpingectomy were performed leaving only a partial section of vagina and urethral stump .
7 whom had a thimble bladder . by marking a triangle on the fundus of the stomach with methylene blue , a 15 cm long base ( in our first experience ) and then 20 cm long ( after the first case ) far from antrum to the fundus was selected .
gastric wedge was brought to the pelvis by passing it through the transverse mesocolon and small bowel mesentery in a straight direction ( figures 1 , 2 ) .
the gastric wedge was anastomosed to the bivalve bladder , after partial cystectomy . in patients
2 and 3 , the gastric pouch was anastomosed to the urethra , and then the two ureters in each case were anastomosed to the new bladder .
two 8fr feeding tubes were put into the ureters as a stent and a three way 22fr foley catheter inside the bladder ( a d.j .
4 and 5 , because of a small flap and a short pedicle , a distal part of the flap was tubularized around a 22 three way catheter and was anastomosed to the membraneous urethra by six sutures with 2 - 0 chromic catgut . at the end of the operation
the bladder was filled with saline solution to evaluate neobladder volume and also urinary leakage .
the operation time for patients 1 to 7 were 3 , 4.52 , 5.5 , 6 , 5 , 6 and 10 hours , respectively ( mean : 325 minutes ) .
intravenous cimetidine 200 mg four times a day , was administered after the operation for 4 - 5 weeks .
ureteral catheter was removed one week after the operation , and hemovac drain one day later ( if the amount of secretion was less than 30 ml ) .
bladder irrigation was performed continuously for the first and second patients , but for patients 3 to 7 , it was stopped . however , after getting more experience in benign conditions ( t.b . ) , bladder irrigation was stopped .
foley catheter was removed four weeks after the operation , after retrograde cystography to assess leakage .
all patients started walking from the third post - op day except patient no . 5 , who experienced a longer operation time and post - op tachyarrhythmia .
fortunately , rare complications occurred from such massive and pr operations . expected complications were summarized in table 1 .
all patients were followed up by renal and bladder us ( ultrasonography ) , ivp ( intravenous pyelography ) and metabolic assay by measuring na , k , bicarbonate , blood and urine ph , and in one case measuring serum gastrin .
2 , 5 , 6 and 7 were living in the current city and had a more precise follow - up compared to patients no . 2 and 4 who lived in other cities .
our follow - up period was 5 - 36 ( mean : 20.2 ) months . in these cases we had one dysuria hematuria syndrome ( which is more common in pediatric patients ) , who had undergone gastrocystoplasty after failed vesicovaginal and contracted bladder . in this case , we prescribed h2 blocker , continuously .  
as we had no urodynamic facility at that time , only one case was sent to a higher advanced center for this purpose and the results are presented , but their bladders capacity and residual urine were measured .
its results are as follows : the neobladder volume was 400 ml in patients 1 , 2 , 4 and 5 but in cases 3 , 6 and 7 , were 310 , 100 and 350 ml , respectively .
final follow - up for patients no . 1 , 3 and 5 were 36 , 24 and 5 months , respectively , and all were in a good condition until that time . in patient
7 was alive with end stage renal disease and awaiting renal transplantation up to writing the article ( we have no waiting list for iranian patients but as a law , a foreigner must introduce a relative live donor from his or her country ) .
one of our patients was a woman who received a urethral catheter due to urinary urge incontinence .
the rest of our patients had acceptable levels of urinary continence ( figures 3 - 12 ) .
2 , 5 , 6 and 7 were living in the current city and had a more precise follow - up compared to patients no . 2 and 4 who lived in other cities .
our follow - up period was 5 - 36 ( mean : 20.2 ) months . in these cases we had one dysuria hematuria syndrome ( which is more common in pediatric patients ) , who had undergone gastrocystoplasty after failed vesicovaginal and contracted bladder . in this case
as we had no urodynamic facility at that time , only one case was sent to a higher advanced center for this purpose and the results are presented , but their bladders capacity and residual urine were measured .
its results are as follows : the neobladder volume was 400 ml in patients 1 , 2 , 4 and 5 but in cases 3 , 6 and 7 , were 310 , 100 and 350 ml , respectively .
final follow - up for patients no . 1 , 3 and 5 were 36 , 24 and 5 months , respectively , and all were in a good condition until that time . in patient
7 was alive with end stage renal disease and awaiting renal transplantation up to writing the article ( we have no waiting list for iranian patients but as a law , a foreigner must introduce a relative live donor from his or her country ) .
one of our patients was a woman who received a urethral catheter due to urinary urge incontinence .
the rest of our patients had acceptable levels of urinary continence ( figures 3 - 12 ) .
sinaiko performed the first gastric neobladder in 1956 after partial cystectomy in a patient with bladder tumor ( 7 ) ; then leong used a gastric pouch for augmentation after tuberculosis cystitis and bladder tumor ( 8) . since then a few articles were published on advantages and disadvantages of this type of procedure .
all authors believe that it is a good segment for bladder replacement in boys ( 9 ) , as well as adults after cystectomy for benign ( 5 ) and malignant diseases ( 10 ) . however , it is still controversial weather to use it as a neobladder in adults after radical cystectomy for bladder tumors .
believed that adult gastric neobladder is associated with poor urodynamic parameters and high incontinence rates ( 1 ) . on the other hand , koraitim et al . reported that stomach is an ideal and suitable segment for bladder augmentation and/or creating a neobladder ( 10 ) .
compared to other segments of the gastrointestinal tract , stomach has a thicker wall , which makes it easy to perform antireflux ureteral anastomosis .
furthermore , in patients with invasive bladder tumor who receive radiotherapy , stomach is far from the field of radiotherapy compared to other parts of the gastrointestinal tract .
moreover , it makes less mucus production , so suprapubic catheter in gastric neobladder is not necessary ( 5 ) ; and the last but not least , stomach is impermeable to most ions especially chloride , which is transported in urine ( 10 ) ; thus , it has a protective effect against acidosis in patients with renal impairment .
one of the most common complications of gastric neobladder or gastrocystoplasty is perforation of the pouch .
studies showed that perforation in gastric pouch is negligible compared to ileal , ileocaecal or sigmoid ones .
therefore , it is an ideal segment in patients with concomitant renal failure and invasive bladder tumors .
our mean operative time was 325 minutes ( 180 - 600 ) compared to 365 ( 300 - 450 ) minutes in wang et al .
study with more than 20 years of experience on gastric replacement therapy ( 3 ) .
there are many intraoperative and postoperative complications such as blood loss , hematemesis , intestinal adhesion , increased serum gastric and cardiac failure ( one case , due to anesthetic problem , is not in this series ) .
santucci et al . performed seven gastric neobladders and concluded that gastric pouch has a smaller capacity with greater incontinence rates ( 2 ) .
they performed urodynamic study after an average of 9.1 months and reported the volume of neobladder as 311 ml .
lin et al . performed eight gastric neobladders ( malignancy in seven and undiversion in one ) with an average follow - up of 9.1 months .
they reported that gastric neobladder capacity reduced to a mean of 309 ml and concluded that routine use of gastric neobladder in adults is not recommended ( 1 ) .
capacity of neobladder is an important factor for incontinence and involuntary contraction ( 11 ) .
the final capacity of gastric neobladder can be determined six months ( 11 ) and one and a half years after the operation ( 12 ) .
wang et al . reported their experiences on nine cases of gastric neobladder by performing it after laparoscopic radical cystectomy , showing a good capacity of pouch and continence ( 3 ) .
gastric neobladder is an ideal procedure after cystectomy for bladder benign and malignant diseases . to prevent ureteral stenosis , we should have adopted to do tension free ureteral reimplant ; however , it is more challenging compared to the rate of continence and is totally related to volume of neobladder and surface of the wedge .
when the volume and surface of the gastric wedge is high , the rate of continence is greater .
nevertheless , we recommend investigating more patients with longer and better follow - up including urodynamic study and gastrin measurement .
 background : there is a controversy regarding the use of gastric pouch for benign and malignant bladder diseases.objectives:the aim of this retrospective study was to report our experience , mostly on gastric neobladder ( not gastrocystoplasty ) for benign and malignant bladder diseases , its complications , outcomes and follow - up results.materials and methods : in this retrospective case series , we described our experience on seven gastric pouches ( 2 gastrocystoplasty and 5 gastric neobladders).results : postoperative complications were rare . 
 continence was defined as bladder capacity over 400 ml . 
 their follow - up period ranged from five months up to writing the article . 
 one of the studied cases is still alive and awaiting renal transplantation.conclusions:gastric pouch is a suitable segment for bladder cystoplasty and neobladder . 
 continence is mostly related to the capacity of pouch . 
1. Background
2. Objectives
3. Materials and Methods
3.1. The Procedure Technique
3.2. Case by Technique
4. Results
4.1. Follow-up
4.2. Urodynamic Study
5. Discussion