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Camey II Detubularized Orthotopic Ileal Neobladder

The Camey II neobladder is a detubularized U-shaped orthotopic ileal bladder substitute developed by Maurice Camey at Centre Médico-Chirurgical Foch, Suresnes (France) in 1987 as a critical evolution of his original Camey I procedure (first performed 1958–1959). The Camey II addressed the universal nocturnal enuresis and high intraluminal pressures that plagued the non-detubularized Camey I by applying the principle of detubularization — opening the ileal segment along its antimesenteric border to disrupt coordinated peristalsis and create a low-pressure reservoir.[1][2][3][4]

Historical Development — From Camey I to Camey II​

Camey I (1958–1987)​

Maurice Camey is credited as a pioneer of orthotopic bladder substitution:[3][4][5]

  • First performed 1958–1959 in Paris — among the first to anastomose an ileal segment directly to the urethra
  • Technique: 40 cm intact (non-detubularized) ileum folded U-shape and anastomosed to urethra; ureters reimplanted via Le Duc-Camey mucosal trough
  • 25-yr experience: 84 patients[4]

Camey I limitations (urodynamically defined):[3][5][6]

  • Universal nocturnal enuresis — tubular ileum maintained physiological peristaltic contractions even at 2 yr[3]
  • Mean pressure at capacity 37 cmH₂O; mean capacity 362 mL; voiding interval only 2.2 hr — insufficient for overnight storage
  • Metabolic acidosis 43%; reflux prevention 86% of renal units
  • All but 2 of 10 Camey I neobladders had cystoplasty contractions at 50–200 mL volumes; the 2 totally continent patients had no contractions[6]

A direct comparison of Camey I vs Studer (detubularized) confirmed that Camey I had smaller capacity, higher pressure, shorter voiding intervals, near-uniform enuresis, and higher reflux.[5]

Camey II (1987)​

Recognizing tubular configuration as the root cause, Camey introduced the Camey II in 1987 incorporating detubularization:[1][2]

  • Ileal segment opened along antimesenteric border disrupting coordinated peristalsis
  • Opened plate folded U-shape; medial edges sutured to form posterior wall — wider, more spherical reservoir
  • Result: low-pressure high-capacity reservoir — the fundamental advance over Camey I

Surgical Technique​

Classic Camey II[1][2][7]​

  1. Bowel isolation — ~ 40–60 cm distal ileum, ~ 15–25 cm proximal to ileocecal valve
  2. Bowel continuity — ileoileal anastomosis
  3. Detubularization — open along entire antimesenteric border
  4. U-fold configuration — single fold; medial edges sutured to form posterior wall
  5. Ureteral reimplantation — Le Duc-Camey mucosal trough technique (see below)
  6. Urethral anastomosis — most dependent point of U → membranous urethra
  7. Anterior closure — suture free edges of U together

Modifications​

  • Stapling (Leandri / Rossignol 1990) — GIA staplers for detubularization and reservoir construction; reduces operative time[1]
  • Serosal-lined antireflux (Muto 2005) — Abol-Enein/Ghoneim serous-lined extramural tunnel applied to GIA-stapler-detubularized Camey II. n = 43, median FU 38 mo: only 1 reflux and 2 ureteroileal strictures (complication rate 6.9%); reservoir construction time ~ 1 hr 45 min[8]

The Le Duc-Camey Ureteral Reimplantation Technique​

One of the most important Camey-group contributions to urinary diversion. Described by Le Duc & Camey 1979; long-term FU published 1987.[9][10][7]

Technique:

  1. Longitudinal trough (sulcus) created in ileal mucosa by incising two parallel lines ~ 3–4 cm long and stripping mucosa between them
  2. Spatulated ureter laid into trough and sutured to edges
  3. Over time, ileal mucosa progressively grows over the ureter creating a natural antireflux mechanism

Le Duc & Camey 1987 outcomes (260 ureters):[9][10]

  • Antireflux effectiveness 85%
  • Stenosis rate < 5%
  • Anastomotic stenosis 4.9% at ≥ 2 yr
  • No obstructions detected after 2 yr — all strictures within first 2 yr
  • Ureteral reimplantation rate 3.7%; nephrectomy for chronic obstruction 2%
  • All strictures at the anastomotic site

Comparative data:

  • Shaaban 1992 randomized comparison vs intussuscepted nipple valve — nipple more effective (0% reflux vs 31% radiographic dilation with Le Duc), though 11 of 12 dilated Le Duc units had stenosis rather than reflux[11]
  • Yamamoto 1995 — Le Duc applied to Kock pouches: 93.6% normal upper tracts, 0% reflux at mean 23 mo[12]
  • Hassan 2007 Y-neobladder 12-yr FU (n=120) — Le Duc vs direct Nesbit: stricture 9.7% vs 0% (p = 0.04) but Le Duc superior in preventing reflux in preoperatively dilated ureters (16.7% vs 40%, p = 0.045)[13]

Functional Outcomes​

Camey 110-pt update (Barré 1996)[2]​

  • 110 patients treated 1987–1991 at CMC Foch
  • Compared directly with the Camey I experience
  • Improvement in capacity and nighttime urinary control with detubularization was "obvious"

Initial 57-pt series (Leandri 1990)[1]​

  • n = 57; FU 3–24 mo
  • Perioperative mortality 0%; only 5 perioperative complications
  • Continence: 50% at 3 mo, 90% at 6 mo (day and night)

Supra-ampullar cystectomy (Terrone 20-yr)[14][15]​

n = 28 (26 Camey II / 2 Camey I) with seminal-vesicle and peripheral-prostate preservation:

  • Median FU 90.5–95 mo
  • 10-yr cause-specific survival 76.7%
  • Potency preserved 90.3–92.8%; antegrade ejaculation maintained 48.3–53.5%
  • Daytime continence 100%
  • Nighttime incontinence 26–29%; CIC 19–20%

Perugia Ileal Neobladder (PIN) — modified Camey II[16]​

Porena 237-patient series with 45 cm detubularized ileum in vertical Y-shape, median FU 64 mo:

ParameterResult
5-yr OS64%
Perioperative mortality1.6%
Daytime continence93.5%
Nighttime continence83.9%
Spontaneous voiding100% (all emptied completely)
Early Clavien III–IV complications27 patients
Most frequent late complicationsReflux, urolithiasis, urethral anastomotic stricture
10-yr FU subgroup (20 pts)Satisfactory functional results maintained

Urodynamic Properties — Camey I vs Camey II vs Other Neobladders​

The fundamental advantage of detubularization:

ParameterCamey I (tubular)Camey II / U-shapedW-shaped (Hautmann)
Capacity362 mL400–500 mL413–550 mL
Pressure at capacity37 cmH₂O15–25 cmH₂O26–30 cmH₂O
Peristaltic contractionsPersistent (even at 2 yr)Decreased over timeDecreased over time
Nocturnal enuresis~ 100%10–30%5–18%
Voiding interval2.2 hr3+ hr3+ hr
Reflux (Le Duc technique)14%15–31% (variable)—

Koraitim demonstrated that detubularized neobladders show decreasing pressure and involuntary contractions over time, while non-detubularized reservoirs show increasing pressure and persistent contractions. Capacity increased in both but more markedly in detubularized segments (109–112% vs 79%).[18]

Minervini 1998 compared U-shaped (single-fold), W-shaped (double-fold), and Studer neobladders — double-reconfiguration reservoirs (W and Studer) showed larger capacity and lower max pressure than U-shaped at all time points; at 12 mo continence and voiding interval were significantly better with double-reconfiguration.[17]

Complications​

Early​

  • Perioperative mortality 0% in Leandri 57-pt; 1.6% in Perugia 237-pt[1][16]
  • Early-complication rate low — only 5 perioperative complications in initial 57[1]
  • Perugia: most early complications Clavien I–II; III–IV in 27/237[16]

Late​

  • Ureteroileal stricture (Le Duc): 4.9% at ≥ 2 yr; all within first 2 yr[7]
  • Reflux 15–31% (variable by technique)[17][11]
  • Urolithiasis — among the most frequent late complications in Perugia series[16]
  • Urethral anastomotic stricture — frequent late complication[16]
  • Metabolic acidosis — 43% in Camey I; mild and treatable with oral alkalinization in detubularized series[3][5]

For pharmacologic management see Vitamin B12 supplementation, Urinary acidifiers & alkalinizers, and Mucus management.

Camey II in Context — Comparison with Contemporary Neobladders​

FeatureCamey ICamey IIStuderHautmann (W)
Year introduced1958198719851986
DetubularizedNoYesYesYes
ConfigurationTubular UU-shaped (single fold)U-shaped + afferent limbW-shaped (quadruple fold)
Ileal length~ 40 cm~ 40–60 cm~ 54–60 cm~ 60–70 cm
Ureteral techniqueLe Duc-CameyLe Duc-CameyNesbit (refluxing) + afferent limbLe Duc-Camey or chimney
Daytime continenceGood (but short intervals)90–93.5%87–93%90–96%
Nighttime continence~ 0% (universal enuresis)70–84%72–79%82–95%
Pressure at capacity37 cmH₂O15–25 cmH₂O~ 20 cmH₂O26–30 cmH₂O

Legacy and Current Status​

Key contributions​

  1. Camey I was among the first orthotopic neobladders ever performed — established the fundamental concept that ileum could be anastomosed to urethra to allow voiding per urethra without a stoma[4][3]
  2. Camey II demonstrated that detubularization was the critical step in converting a high-pressure tubular conduit into a low-pressure reservoir — a principle now universally applied in all modern neobladder designs[1][2]
  3. The Le Duc-Camey mucosal trough technique became one of the most widely adopted antireflux methods in orthotopic neobladder surgery (85% antireflux effectiveness, < 5% stenosis)[9][10]
  4. The Camey II directly influenced the Hautmann (W-shaped) neobladder, which used the Le Duc-Camey technique and extended detubularization to a quadruple-fold configuration[19]

Current use​

  • Rarely performed today in its original U-shape form — superseded by Studer and Hautmann (double reconfiguration) which achieve larger capacity and lower pressures[17]
  • The concept lives on in modified forms — most notably the Perugia Ileal Neobladder (PIN) with Y-shape configuration achieving 93.5% / 83.9% continence in 237 patients[16]
  • The Y-neobladder (Fontana 2004) — another Camey II derivative using only 40 cm ileum; comparable results with 15–20-min construction time and 1% ureteroileal stricture rate[20]
  • Le Duc-Camey ureteral reimplantation remains in use, though many centers have shifted to simpler refluxing (Nesbit/Wallace) anastomoses with afferent limbs based on USC-STAR evidence that antireflux mechanisms do not improve long-term renal outcomes[21][13]

Key Takeaways​

  1. The Camey II was a landmark advance over Camey I — detubularization eliminates the high-pressure peristaltic contractions responsible for universal nocturnal enuresis in tubular neobladders
  2. The Le Duc-Camey mucosal trough achieved 85% antireflux effectiveness with < 5% stenosis — durable long-term
  3. As a single-fold (U-shaped) detubularized reservoir, Camey II produces lower capacity and higher pressures than double-fold (W or Studer) configurations — the reason it has been largely replaced
  4. The Camey II's legacy is its proof of concept — detubularization transforms ileal reservoirs from high-pressure conduits into compliant low-pressure bladder substitutes — the principle underpinning every modern orthotopic neobladder

See Also​

References​

1. Leandri P, Rossignol G, Gautier JR, et al. "Ileal low-pressure bladder replacement: Camey type II. Stapling technique and preliminary results (57 cases, 1987–1989)." Eur Urol. 1990;18(3):161–165. doi:10.1159/000463900

2. Barre PH, Herve JM, Botto H, Camey M. "Update on the Camey II procedure." World J Urol. 1996;14(1):27–28. doi:10.1007/BF01836341

3. Roehrborn CG, Teigland CM, Sagalowsky AI. "Functional characteristics of the Camey ileal bladder." J Urol. 1987;138(4):739–742. doi:10.1016/s0022-5347(17)43357-x

4. Lilien OM, Camey M. "25-year experience with replacement of the human bladder (Camey procedure)." J Urol. 2017;197(2S):S173–S179. doi:10.1016/j.juro.2016.10.106

5. Carini M, Serni S, Scelzi S, et al. "Orthotopic ileal bladder: clinical, urodynamic and metabolic evaluation." Eur Urol. 1992;22(2):99–105. doi:10.1159/000474733

6. Goldwasser B, Rife CC, Benson RC, Furlow WL, Barrett DM. "Urodynamic evaluation of patients after the Camey operation." J Urol. 1987;138(4):832–835. doi:10.1016/s0022-5347(17)43389-1

7. Lugagne PM, Hervé JM, Lebret T, et al. "Ureteroileal implantation in orthotopic neobladder with the Le Duc-Camey mucosal-through technique: risk of stenosis and long-term follow-up." J Urol. 1997;158(3 Pt 1):765–767. doi:10.1097/00005392-199709000-00019

8. Muto G, Bardari F, D'Urso L. "New serosal-lined antireflux ureteroileal implantation technique on a GIA stapler detubularised ileal neobladder: technical considerations and results." Eur Urol. 2005;48(5):826–830. doi:10.1016/j.eururo.2005.03.011

9. Le Duc A, Camey M, Teillac P. "An original antireflux ureteroileal implantation technique: long-term followup." J Urol. 1987;137(6):1156–1158. doi:10.1016/s0022-5347(17)44433-8

10. Le Duc A, Camey M, Teillac P. "Antireflux uretero-ileal implantation via a mucosal sulcus." Ann Urol. 1987;21(1):33–34.

11. Shaaban AA, Gaballah MA, el-Diasty TA, Ghoneim MA. "Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures." J Urol. 1992;148(4):1156–1161. doi:10.1016/s0022-5347(17)36847-7

12. Yamamoto A, Kanayama H, Naruo S, Takigawa H, Kagawa S. "The Camey-Le Duc antireflux technique for the Kock pouch: evaluation of the upper urinary tract." Eur Urol. 1995;27(3):236–240. doi:10.1159/000475168

13. Hassan AA, Elgamal SA, Sabaa MA, Salem KA, Elmateet MS. "Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow-up." Int J Urol. 2007;14(4):300–304. doi:10.1111/j.1442-2042.2006.01716.x

14. Terrone C, Porpiglia F, Cracco C, et al. "Supra-ampullar cystectomy and ileal neobladder." Eur Urol. 2006;50(6):1223–1233. doi:10.1016/j.eururo.2006.07.049

15. Terrone C, Cracco C, Scarpa RM, Rossetti SR. "Supra-ampullar cystectomy with preservation of sexual function and ileal orthotopic reservoir for bladder tumor: twenty years of experience." Eur Urol. 2004;46(2):264–269. doi:10.1016/j.eururo.2004.03.006

16. Porena M, Mearini L, Zucchi A, et al. "Perugia ileal neobladder: functional results and complications." World J Urol. 2012;30(6):747–752. doi:10.1007/s00345-012-0985-z

17. Minervini R, Morelli G, Fontana N, Minervini A, Fiorentini L. "Functional evaluation of different ileal neobladders and ureteral reimplantation techniques." Eur Urol. 1998;34(3):198–202. doi:10.1159/000019712

18. Koraitim MM, Atta MA, Foda MK. "Early and late cystometry of detubularized and nondetubularized intestinal neobladders: new observations and physiological correlates." J Urol. 1995;154(5):1700–1702.

19. Hautmann RE, Egghart G, Frohneberg D, Miller K. "The ileal neobladder." J Urol. 1988;139(1):39–42. doi:10.1016/s0022-5347(17)42283-x

20. Fontana D, Bellina M, Fasolis G, et al. "Y-neobladder: an easy, fast, and reliable procedure." Urology. 2004;63(4):699–703. doi:10.1016/j.urology.2003.11.015

21. Skinner EC, Fairey AS, Groshen S, et al. "Randomized trial of Studer pouch versus T-pouch orthotopic ileal neobladder in patients with bladder cancer." J Urol. 2015;194(2):433–439. doi:10.1016/j.juro.2015.03.101