Le Bag Ileocolonic Neobladder
The Le Bag is an orthotopic reservoir constructed from detubularized ileum and colon. Light and Engelmann reported the original four-patient experience in 1986.[1][2][3][4] Subsequent modifications changed the outlet, ureteral implantation and reservoir construction.[1][2][3][4]
Use the Urinary Diversion Principles for patient selection, urethral suitability, emptying requirements and surveillance.[5] A 2026 systematic review of 17 studies (one randomized trial and 16 cohorts) associated ileal neobladders with better nighttime continence than colonic neobladders.[12]
Historical Development
- 1986. Light and Engelmann described the ileocolonic pouch in four patients as a highly compliant, low-pressure reservoir made by disrupting directional bowel peristalsis.[1]
- 1992. Vara and Shanberg modified the outlet in 17 patients (see the table below).[2]
- 1993. Bejany and Politano reported a modified ileocolonic bladder with trigone-like ureteral placement in 25 patients.[3]
- 1996. Kolettis and colleagues at the Cleveland Clinic reported 38 men, comparing hand-sewn with stapled construction and refluxing with tunneled ureteral implantation.[4]
- 1999. Eisenberger and colleagues summarized the Johns Hopkins experience with a composite ileocolic neobladder from 1986 to 1998.[9]
- 2004. Baniel and Tal described the B-Bladder, a Le Bag reservoir with a Studer-like isoperistaltic ileal chimney.[6]
- 2006 and 2009. Two randomized comparisons with ileal neobladders were published (Khafagy, Chen).[8][7]
Construction and Named Modifications
Detubularization and folding aim to create a capacious reservoir with low storage pressure. Neither use of two bowel segments nor proximity to the pelvis guarantees compliance or a tension-free outlet.[1][3][6][7] Ureteral drainage depends on the actual implantation or afferent-limb design.[1][3][6][7]
The core construction sequence is to isolate adequately perfused ileocolonic bowel, restore gastrointestinal continuity, detubularize and reconfigure the reservoir, establish a dependent urethral outlet without tension, and implant the ureters according to the selected modification. Segment dimensions and outlet configuration are technique-specific.[4] For example, Kolettis used approximately 20 cm each of ileum and cecum.[4] In the original operation the outlet was a tail of nondetubularized ileum anastomosed to the urethra. Vara and Shanberg replaced that tail with a direct urethral-cecal anastomosis because nocturnal incontinence persisted in a substantial number of patients.[2]
| Modification | Operative distinction | Evidence and limits |
|---|---|---|
| Original Light–Engelmann | Composite ileocolonic bladder substitution | Initial four-patient report.[1] |
| Vara–Shanberg | Direct urethral–cecal anastomosis replaced the original tubular ileal outlet in 13 patients | The published 17-patient series also included four cutaneous outlets. Its 94% overall day/night continence cannot be assigned to 17 orthotopic neobladders; one of the 13 urethral–cecal patients required intermittent catheterization.[2] |
| Bejany–Politano | Ureteral implantation near the reservoir outlet in a trigone-like arrangement, with the left ureter not crossed | Intended to facilitate upper-tract access. The 25-patient report describes experience over five years, with individual follow-up 3–66 months, not five-year observation of every patient.[3] |
| Cleveland Clinic modification | Absorbable staples used in 22/38 pouches; freely refluxing Bricker implantation in 21/38 | Small, nonrandomized construction comparisons; no complications specifically related to staples were reported.[4] |
| B-Bladder | Ileocolonic reservoir with a Studer-like isoperistaltic ileal chimney for ureteral implantation | Single-surgeon series of 29 patients, median follow-up 3.4 years.[6] |
The chosen segment must reach the urethra while retaining perfusion, and the ureteral anastomoses must remain unobstructed as the pouch fills. A modification's presumed mechanical benefit must be separated from its demonstrated clinical results.[4][6][5]
Comparative Evidence
Chen randomized study and the Cochrane interpretation
Chen compared an ileocolonic neobladder with a purely ileal neobladder in men undergoing radical cystectomy for bladder cancer.[7] The Cochrane review records 90 patients randomized, 85 accepting their allocation (42 ileocolonic and 43 ileal), with complete six-month evaluation in 33 and 38, respectively.[7][5] The published abstract describes those 71 evaluated patients.[7][5]
| Six-month outcome | Ileocolonic | Ileal |
|---|---|---|
| Complete daytime continence | 90.9% | 89.4%[7] |
| Reported nighttime functional continence | 48.5% | 76.3%[7] |
| Reservoir compliance | Lower | Higher |
The study found better nighttime functional continence and compliance with the ileal reservoir. The study did not test equivalence in daytime continence. Lower compliance was a proposed contributor to nocturnal leakage.[7]
The Cochrane analysis reported a risk ratio of 0.35 (95% CI 0.15–0.79) for nighttime incontinence with ileal versus ileocolonic reconstruction in this study, using its specified unsatisfactory-continence outcome.[5]
Khafagy trial and the combined evidence
Khafagy randomized 60 patients to ileal (29) or ileocecal (31) neobladders. Reported daytime continence was 93% and 90%, respectively; mean postvoid residual urine volume was lower in the ileocecal group (12 versus 90 mL).[8] During two years of follow-up, the study reported preserved pelvicalyceal systems in 93% of the ileocecal group versus 85% of the ileal group.[8] The Cochrane reviewers noted that analyses of paired renal units did not account properly for their dependence.[8][5]
Across Chen and Khafagy, the Cochrane pooled estimate for nighttime incontinence was RR 0.62 (95% CI 0.13–2.87), with substantial heterogeneity and no statistically significant overall difference. The review, whose search ended in October 2011, found the randomized evidence too limited to establish a generally superior reconstruction.[5]
Historical Outcomes in Context
| Report | What was actually measured | Interpretation |
|---|---|---|
| Bejany–Politano, 25 patients | 100% reported daytime and 92% nighttime continence; no reflux reported; four ureters developed strictures; early (3-month) and late complication rates 18% and 16% | Small mixed-indication cohort (20 cancer, four interstitial cystitis, one undiversion), including 21 men and four women, mean age 61 years.[3] |
| Kolettis, 38 men | 91% daytime continence; 80% completely dry or only mildly incontinent at night | The nighttime result is not 80% strict dryness. Construction and implantation subgroups were small and nonrandomized.[4] |
| Johns Hopkins experience, 1986–1998 | Reported 76% continent both day and night, 3% nocturnal enuresis only, 15% using intermittent catheterization, 3% bothersome daytime stress incontinence among patients evaluated for the report; early and late complication rates 11% and 30% | The publication's 12-year institutional experience is not 12-year follow-up of each patient. Its potency result should not be used as a Le Bag-specific nerve-preservation benefit.[9] |
| B-Bladder, 29 patients | Recurrent UTI 17% and ureteroenteric stricture 3%; median follow-up 3.4 years | The separately reported median survival of 71.1 months is not the median follow-up duration or a comparative functional outcome.[6] |
In a 37-patient modified Le Bag cohort that included 16 women, female sex was associated with longer time to full daytime continence.[13] These cohorts differ in outlet construction, selection, follow-up and definitions of continence.[5]
Metabolic and Functional Follow-up
Ileocolonic reservoirs can produce hyperchloremic metabolic acidosis. In the Kolettis cohort, median bicarbonate decreased from 28 to 24 mmol/L, with a reported association between pouch length and the biochemical change (r = 0.58). Persistent biochemical acidosis requires assessment even in the absence of symptoms; treatment depends on its severity, renal function and clinical context. See Urinary Acidifiers & Alkalinizers.[4]
Terminal ileal exclusion can affect bile-salt and vitamin B12 absorption.[14] EAU follow-up guidance advises annual vitamin B12 measurement after cystectomy with bowel diversion, because low levels have been reported in 17% of patients with bowel diversion (section 7.4 text; no strength rating).[10] Continue functional follow-up for emptying difficulty, residual urine, continence, renal deterioration, obstruction, infection, stones and metabolic abnormalities; investigate changes.[10]
Orthotopic-diversion counseling includes the possibility of retention requiring intermittent catheterization.[11] The ability and willingness to catheterize if emptying becomes inadequate remain part of that assessment. Use the diversion principles for the shared surveillance and catheterization plan, and the B12 supplementation hub for deficiency management.
Clinical Role
Le Bag is a historical and selected ileocolonic reconstructive option. Its principal educational value is the relationship between reservoir geometry, outlet design and upper-tract drainage.[4][7][5]
See Also
References
1. Light JK, Engelmann UH. "Le Bag: Total Replacement of the Bladder Using an Ileocolonic Pouch." J Urol. 1986;136(1):27–31. doi:10.1016/s0022-5347(17)44715-x
2. Vara AR, Shanberg AM, Sawyer DE, Tansey LA, Martin DC. "Modification of Le Bag Ileocolonic Pouch With Improved Results. Review of 17 Cases." Urology. 1992;40(3):221–6. doi:10.1016/0090-4295(92)90478-f
3. Bejany DE, Politano VA. "Modified Ileocolonic Bladder: 5 Years of Experience." J Urol. 1993;149(6):1441–4. doi:10.1016/s0022-5347(17)36410-8
4. Kolettis PN, Klein EA, Novick AC, Winters JC, Appell RA. The Le Bag orthotopic urinary diversion. J Urol. 1996;156(3):926–930. doi:10.1016/S0022-5347(01)65664-7. PMID:8709365.
5. Cody JD, Nabi G, Dublin N, et al. "Urinary Diversion and Bladder Reconstruction/Replacement Using Intestinal Segments for Intractable Incontinence or Following Cystectomy." Cochrane Database Syst Rev. 2012;(2):CD003306. doi:10.1002/14651858.CD003306.pub2
6. Baniel J, Tal R. "The 'B-Bladder' — an Ileocolonic Neobladder With a Chimney: Surgical Technique and Long-Term Results." Eur Urol. 2004;45(6):794–8. doi:10.1016/j.eururo.2004.01.013
7. Chen Z, Lu G, Li X, et al. "Better Compliance Contributes to Better Nocturnal Continence With Orthotopic Ileal Neobladder Than Ileocolonic Neobladder After Radical Cystectomy for Bladder Cancer." Urology. 2009;73(4):838–43; discussion 843–4. doi:10.1016/j.urology.2008.09.076
8. Khafagy M, Shaheed FA, Moneim TA. "Ileocaecal vs Ileal Neobladder After Radical Cystectomy in Patients With Bladder Cancer: A Comparative Study." BJU Int. 2006;97(4):799–804. doi:10.1111/j.1464-410X.2006.05996.x
9. Eisenberger CF, Schoenberg M, Fitter D, Marshall FF. "Orthotopic Ileocolic Neobladder Reconstruction Following Radical Cystectomy: History, Technique and Results of the Johns Hopkins Experience, 1986–1998." Urol Clin North Am. 1999;26(1):149–56, ix. doi:10.1016/s0094-0143(99)80012-3
10. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Follow-up, section 7.4. Guideline.
11. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer. Version 3.2026. August 6, 2026. Discussion MS-18. Guideline.
12. Li Y, Liu Y. "Ileum vs Colon for Neobladder Reconstruction After Radical Cystectomy: A Systematic Review and Meta-Analysis." Urol J. 2026;23(4):122–132. doi:10.22037/uj.v23i04.8695
13. Nassar OAH. "Modified Le Bag Pouch After Radical Cystectomy: Continence, Urodynamic Results and Morbidity." J Egypt Natl Canc Inst. 2010;22(1):29–39. PMID:21503004
14. Vasdev N, Moon A, Thorpe AC. "Metabolic Complications of Urinary Intestinal Diversion." Indian J Urol. 2013;29(4):310–315. doi:10.4103/0970-1591.120112