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Tinoco et al. Mini-invasive Surg 2021;5:28 https://dx.doi.org/10.20517/2574-1225.2021.35 Page 7 of 11

incision, reducing the surgical risks. The global recurrence rates following surgical treatment of PSH in the
[26]
largest systematic review were 27%-50% .
Another approach to PSH is prevention. The first randomized controlled study on the prevention of PSH
after ileal conduit urinary diversion following radical cystectomy has been published with promising results.
The authors concluded that the addition of a prophylactic sublay mesh decreases the risk of PSH, with
incidences at 24 months of 11% in the intervention group compared to 23% in the control group. There was
a small increase in median intraoperative time of ~50 min and no greater risk of mesh-related
complications. As an increased BMI was also associated with a higher risk of PSH in this study, the authors
recommend the use of this prophylactic measure especially in obese patients. Studies with longer follow-up
[28]
periods and health-economic analysis can clarify the role of the prophylactic mesh in a wider population .

Conduit deformities
Conduit stricture and conduit elongation are possible complications of this diversion, poorly defined and
[15]
reported in the literature. Shimko et al. reported conduit strictures in 2.4% of patients at a median of 9.4
years. These complications are reportedly less frequent than stomal complications.

Orthotopic neobladder
Rupture
Neobladder rupture is a rare but feared complication, possibly life-threatening. In large series of neobladder
patients by Hautmann et al. , 3 in 923 patients had neobladder rupture. Possible causes are perforation
[16]
during catheterization, external trauma like car accidents, or outlet obstruction by a mucous plug. It can
also happen spontaneously, for example in acutely or chronically overdistended reservoirs with wall
ischemia or in patients previously submitted to pelvic irradiation. Timed micturition and post void residual
volume surveillance (either with echography or catheterization) are advised in order to prevent this
complication. In the event of rupture, these patients often present with an acute abdomen and need a
relaparotomy to drain the urinoma and to repair the perforation or construct a substitute diversion.
Alternatively, there are some descriptions of a conservative approach with neobladder catheterization,
bilateral nephrostomies, and abdominal drain, in strictly selected patients with a mild presentation and
hemodynamic stability .
[29]

Fistula
Urinary diversion-enteric fistula is a rare complication, occurring in less than 2% of the patients submitted
to radical cystectomy. Few studies are published on this complication and most involve neobladder patients.
The most common and characteristic presentation is fecaluria, but pneumaturia and recurrent UTIs are
other complaints. Diagnostic investigation with a CT usually shows air in the intestinal reservoir; if oral
contrast is administered, it can appear in the urinary system. Msezane et al. report the location of the
[30]
fistula to be more frequently from the small bowel anastomosis to the anterior neobladder wall. Small
fistulas can be treated conservatively, with total parenteral nutrition, bladder drainage and treatment of
sepsis, if present. For bigger fistulas or in cases of conservative treatment failure, open repair is the gold
standard.

In women submitted to vaginal-sparing radical cystectomy with orthotopic neobladder creation, a
neobladder-vaginal fistula can form in 2.7%-8.8%, result of a much thinner neobladder wall . Injury to the
[31]
vaginal wall during dissection of the posterior bladder wall and urethra is an important risk factor, in which
case conversion to other urinary diversion may be advisable . Omental flap interposition between the
[32]
neobladder and the vaginal stump during cystectomy or avoidance of overlapping suture lines are