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Page 8 of 11 Tinoco et al. Mini-invasive Surg 2021;5:28 https://dx.doi.org/10.20517/2574-1225.2021.35

[31]
preventive measures, although it may not always prevent fistulization .

These patients present with urinary incontinence and the fistula can be confirmed by cystoscopy or voiding
cystography. Conservative management is invariably unsuccessful. The initial treatment option is a
[31]
multilayered fistula closure via a transvaginal approach ; interposition with a Martius flap is an alternative,
particularly important in recurrent fistulas [33,34] . In case of failure of the transvaginal approach, a
transabdominal approach or conversion to a cutaneous diversion may be needed .
[31]

Hypercontinence
Failure to empty the neobladder and urinary retention is much more frequent in women than in men.
Neobladder patients with emptying failure can present with urinary retention but also with recurrent UTIs,
hydronephrosis, or overflow incontinence.

The risk of retention increases with time, and emptying failure rates range from 4% to 8% in men and 24%
to 62.5% in women [35,36] .

The cause of urinary retention in female neobladder recipients is still controversial. The literature ascribes
the retention in women more to mechanical factors than functional or neurogenic ones; an explanation
given for this chronic retention is a urethral “kinking” by prolapse of the vaginal stump with herniation of
the posterior pouch through the anterior vaginal wall, due to lack of proper back support. Ali-El-Dein
et al. focused on this matter and defined chronic retention by a post-void residue of 20% of mean
[37]
maximal pouch capacity (approximately 100 mL). They reported a chronic retention rate of 16% and
provide some surgical modifications to prevent this complication: reinforcing the back support of the
neobladder with an omental flap, suspending the vaginal wall by the round ligaments or peritoneum, or
suspending the pouch ventrally to the back of the rectus muscle . Genital sparing surgery, when possible, is
[37]
another alternative. Other possible causes are large capacity pouches due to excessive bowel segment length
or even autonomic denervation of the urethra .
[36]
After diagnosis of chronic retention, temporary measures involve manual reduction of the prolapse during
voiding or the use of a pessary; surgical revision with ventral suspension of the pouch can also be tried .
[37]
[35]
Despite that, they might need intermittent catheterization. In a study by Ahmadi et al. , 9.5% of male
patients needed at least one catheterization per day and 1 patient could not urinate without catheterization.
[35]
Intermittent self-catheterization was most commonly started during the first post-operative year .
Urinary retention can less frequently be due to subneovesical obstruction either by tumour recurrence,
stenosis of the urethral anastomosis, or the urethra itself; the reported rates of these complications on one
[16]
study were 1.1%, 1.2%, and 0.9%, respectively, and in this study all strictures were treated by endoscopy .
Therefore, patients with emptying failure should undergo urethrocystoscopy to identify these possible
causes.

Incontinence
Urinary incontinence is a very subjective complication. Its rates in the literature vary between daytime (7%-
13%) and nighttime (14%-43%) and depend greatly on the type of questionnaire used. A more objective way
of evaluating urinary incontinence is pad weight measurement, but it also lacks standardizing, and an
[35]
alternative measure is the number of pads per day . This heterogeneity plus the variety of possible
procedures (such as cystoprostatectomy, pelvic exenteration, vaginal-sparing techniques, and nerve-
sparing) hinders the comparison of different studies .
[38]