1. Hassan Farsi, Anmar Nassir, Hesham Saada, Rami Salawi

2. Bladder caner 63,210 new cases Male to female 3:1 All cancer cases Men 4 th common cancer 6.6% Women 9 th common cancer 2.4% % Age middle-aged and elderly people.

3. Bladder Cancer - Pathology TCC >90% SCC 5-7% chronic irritation stones, foleycatheter Schistosomiasis] ADENOCARCINOMA 1-2% urachal carcinoma, cystitis glandularis Rule out metastatic source. STAGING Superficial versus Infiltrating Tumor Localized versus Locally Extensive or Metastatic

4. INDICATIONS of RADICAL CYSTECTOMY Muscle-invasive bladder cancer Recurrent T1 disease or CIS unresponsive to intra-vesical chemotherapy Palliative procedure when the symptoms of the disease are severe Severe hematuria Severe frequency

5. Indications of Urinary Diversion Dangerous bladder Bladder cancer Pelvic Malignancy Useless bladder Neurogenic Contracted (T.B,B.Irrad) Vesicle fistula Absent bladder Congenital anomalies (Ectopia ) Abol-enein,H 2000

6. Goals of Continent Urinary Diversion Construction of a complaint reservoir Detubularisation and Double folding Protection of the upper tracts Controlled reservoir emptying (continence) Abol-enein,H 2000

7. Ideal Orthotopic Bladder Substitute Technical simplicity Constructed from a minimal bowel length Complaint Protects the upper tract. Continent. Minimal metabolic and nutritional consequences Abol-enein,H 2000

8. REFLUXING OR ANTIREFLUXING ANASTOMOSIS Considerable controversy Potential advantage of anti reflux as long as it does not add a risk of obstruction. Ghoneim, 2002 No Explicit evidence of its necessity Anti refluxing Uretero-intestinal anastomosis in low pressure high capacity reservoir is unnecessary. Prospective controlled randomized study is required Pantuk,2000 & Hohnfeller,2002

9. To assess our experience and results of patients undergoing: Radical Cystectomy and Orthotopic Neobladder Reconstruction

10. MATERIALES & METHODS

11. Number23 Mean Age58.8 Y Sex22 Males 1 Female Duration Of Follow Up26 (6-39) months Patient

12. Method Radical Cystectomy & W-Neobladder. Ureteral re-implantation: SLEMT (Abol-Enein & Ghoneim,1993)=8 Pts Our modification of studier hyperperstaltic ileal limb,15 Pts 2 short ileal limbs (each,5-cm long) instead of one (regular studer limb).

13. Patient selection ( Exclusion criteria) Renal profileSCr: >180 cCr: <45ml/min Hepatic dysfunctionx Unfit for surgery and Psychiatric patient x frozen section from the cut urethral margin and /or pelvic LN +ve

14. SLEMT Radical Cystectomy & W-Neobladder. 5cm two long chimney with direct anastomosis

15. Post Operative Evaluation Histopathologcal examination of the Cystectomy specimens Follow up evaluation on regular intervals Renal profiles CBC UA and Cx U/S and /or IVU Pouchogram when indicated CT Bone scan Endoscopy AUG

16. RESULTS

17. TUMOR CHARACTERISTICS (HISTOPATHOLOGY RESULTS) TUMOR CHARACTERISTICS histopathNo. patients Cell typeTCC19 SCC4 GradeLG9 HG14 LN-ve23 +ve0

18. Age Distribution AgeNo. patients% <4000% 41-50418% 51-601148% 61-70834% >7000%

19. Early Complications Type of complication Mortality DVT URINARY LEAKAGE BROKEN URETERAL STENS Prolonged ileus

20. Renal and electrolytes profiles SCr Na K CL HCO3 RefluxingAnti Reflux

21. Continence Status Continence status Day timecontinent Stress incont Total incont Night timecontinent Noct enuresis Total incont

22. Voiding pattern TimeNumber of frequency No. patients% Day time Night time

23. Late Complications Local recurrence &/or distance Mets Ureteral stricture Urine retention (mucus) Total urinary incont

24. Radiographic Evaluation Radiology FLUNo. patients% IVU/US Ascending Urothrogram /Pouchogram

25. Preoperative Bladder tumour

26. I V U

27. Pouchogrphy+VCUG SLEMT

28. Pouchogrphy + VCUG + IVU 5cm Two Long Chimney With Direct Anastomosis

29. Early Post Op Urethroileal Leakage 2 wk More Foleys catheter drainage 3 wk post operative

30. Early Post Op Broken Unrecognized External Ureteral Stent SLEMT EASY CYSTOSCOPY + STENT REMOVAL EASY LOCALIZATION OF BOTH URETERAL ORIFICE

31. Early Post Op Broken External Ureteral Stent 5cm Two Long Chimney With Direct Anastomosis Antegrade insertion of Guide wire then Cystoscopy and URS and removal of DJ Stent

32. Uretero-Ileal Anastomosis Stricture

33. Reflux 5cm two long chimney with direct anastomosis

34. Conclusions Radical Cystectomy, followed by the construction of orthotopic W-shaped ileal Neobladder results in a near-normal- functioning orthotopic reservoir that can be safely offered to Suitable patients. Well designed Prospective controlled randomized study regarding refluxing and anti-refluxing anastomosis is required.