Dr. Eila Skinner on what makes neobladder reconstruction an innovation in urology

Eila C. Skinner, MD

Urology Times® is celebrating its 50th anniversary in 2022. To mark the occasion, we are high-lighting 50 of the top innovations and developments that have transformed the field of urology over the past 50 years. In this installment, Eila C. Skinner, MD, discusses neobladder reconstruction in patients undergoing radical cystectomy. Skinner is a urologic oncologist and Thomas A. Stamey research professor of urology at Stanford Health in Stanford, California.

Could you please provide an overview of the development of the neobladder?

Historically, almost all urinary diversion was done with a stoma, the so-called "ileal conduit."That was developed in the 1950s and became very much the standard of care. Although there were forays into continent diversion prior to the 1980s, it really took off in that decade. It was toward the end of the 1980s that people started realizing it was safe to preserve the urethra and to do a neobladder reconstruction. First, they figured out how to do it in men, and then, several years later, they figured out that you could do it safely in women as well.

What makes the neobladder an innovation in urology?

Prior to the availability of the neobladder, many patients would essentially refuse treatment for their bladder cancer because they didn't want to have to wear a bag for the rest of their lives. Although there are many other people around the world who developed these types of diversions, what we saw when I was at the University of Southern California with Donald Skinner, MD, was that lots of patients would decide to have treatment because they found that they could have a reconstruction option. Instead of wearing a bag on the outside, these patients can urinate normally. It's not perfect; you have to sort of retrain it, and there are some downsides to it. But it's the closest that we can get to, essentially, an artificial bladder. All the attempts to do that out of plastic have been unsuccessful. This is using your own tissues and your own bowel to essentially make a bladder replacement.

How has the neobladder improved quality of life for patients undergoing radical cystectomy?

There is controversy about this, actually, because most of the attempts to measure quality of life, comparing a patient with a neobladder to a patient with a conduit, have not really been able to show that one was necessarily better than the other. I think part of that is because patients adapt to whatever they have to adapt to. If you had to have a colostomy tomorrow, it might not be what you would pick, but a few years later, you would have learned how to live with it and be able to do the things that you normally do. So I think those attempts to compare one to the other have been difficult to really measure a difference. Having said that, about half of our patients, especially men, undergo a neobladder reconstruction. And when I see a patient back in the office who's completely dry, urinating normally, going on 100-mile bike rides, and doing his normal activities, the neobladder seems better to me. Now, not everybody has that outcome; if a patient doesn't regain their continence, then I think it may not be better. Part of it is a matter of picking the right patients and making sure their expectations are accurate.

Are there any other future innovations in urinary diversion that you anticipate in the next several years?

There have been a whole lot of people working on tissue engineering. It would seem like the perfect answer would be to essentially create a bladder out of your own tissues. Folks have actually tried that and, to some extent, there have been some successes. The tricky part is it's one thing to actually grow a tissue that has mucosa on the inside and some smooth muscle on the outside. But then you have to attach it to the ureters, to the kidneys, and you have to attach it to the urethra or the skin. That's a problem that nobody has been able to overcome so far, because those tend to not connect well. They either scar down or they leak. It's quite a tricky process. I do think someday that might be possible.

Another big goal of all of us who treat bladder cancer is to not have to take out the bladder in the first place. There is lots of work going on trying to define medical treatments or radiation treatments that are successful. But today, there's still a large number of patients who need a cystectomy in order to survive. But lots of people are trying to come up with new ideas.

I don't think a truly artificial bladder made out of plastic or any kind of nonorganic material is ever going to work. That's also been tried, and there are just too many difficulties to overcome.