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Le Bag Ileocolonic Neobladder

The Le Bag is a detubularized ileocolonic (ileocecal) orthotopic neobladder first described by J. Kevin Light and Udo H. Engelmann at Baylor College of Medicine in 1986.[1] It was one of the earliest techniques to combine detubularized terminal ileum and cecum into a single composite reservoir, achieving a highly compliant, low-pressure bladder substitute by disrupting directional bowel peristalsis across two intestinal segments with different motility patterns.[1][2]

Historical Development​

  • 1986 — Light and Engelmann published the original 4-patient series demonstrating a highly compliant low-pressure ileocolonic reservoir.[1]
  • 1992 — Vara and Shanberg published a modified Le Bag (n = 17) replacing the non-detubularized ileal tail outlet with direct urethral-cecal anastomosis, achieving 94% combined day/night continence.[2]
  • 1993 — Bejany and Politano reported a modified ileocolonic bladder (n = 25, 5-year follow-up) with 100% daytime and 92% nighttime continence and a trigone-like ureteral implantation pattern.[3]
  • 1996 — Kolettis, Klein, and Novick (Cleveland Clinic) published the largest Le Bag series (n = 38) examining hand-sewn vs stapled construction and refluxing vs tunneled ureteral implantation.[4]
  • 1999 — Eisenberger, Schoenberg, and Marshall (Johns Hopkins) reported the 12-year ileocolic neobladder experience (1986–1998) with 76% combined continence and 45% potency preservation.[5]
  • 2004 — Baniel and Tal introduced the "B-Bladder" — a Le Bag reservoir with a Studer-like isoperistaltic ileal chimney for ureteral anastomosis.[6]
  • 2009 — Chen et al. published the only RCT comparing Le Bag with a purely ileal neobladder (n = 71), demonstrating significantly worse nocturnal continence with the ileocolonic technique.[7]

Design Principles and Rationale​

The Le Bag was designed to exploit the unique advantages of combining two different intestinal segments — terminal ileum and cecum — in a single detubularized reservoir.[1][2]

  1. Disruption of directional peristalsis — combining ileum and cecum (which have different peristaltic patterns and innervation) disrupts coordinated bowel contractions at the ileocecal junction.
  2. Detubularization — opening both segments along the antimesenteric border (ileum) and taenia (cecum) further disrupts peristalsis and increases capacity while lowering intraluminal pressure (Laplace's law).
  3. Natural antireflux mechanism — the ileocecal valve region can be utilized for tunneled ureteral reimplantation.
  4. Anatomic advantage — the cecum and terminal ileum sit naturally in the right lower quadrant, close to the pelvis, facilitating tension-free urethral anastomosis.
  5. Relative ease of construction — designed to be simpler than the Kock pouch (no intussusception nipple) while achieving comparable urodynamic properties.[2]

Surgical Technique​

Original Le Bag (Light & Engelmann, 1986)​

  1. Bowel isolation — approximately 20 cm of terminal ileum and 20 cm of ascending colon/cecum are isolated on their mesentery, preserving the ileocolic artery.[1]
  2. Bowel continuity — ileoascending colonic anastomosis restores GI continuity.
  3. Detubularization — both segments are opened along the antimesenteric border (ileum) and along the taenia (cecum/colon).
  4. Plate configuration — opened ileal and cecal plates are laid flat to create a large composite plate.
  5. Reservoir construction — the plate is folded and sutured into a spheroidal, low-pressure reservoir.
  6. Urethral anastomosis — in the original technique, a tail of non-detubularized ileum was used as the outlet, anastomosed to the membranous urethra (subsequently identified as the source of nocturnal incontinence).
  7. Ureteral reimplantation — ureters reimplanted into the colonic portion, often with a tunneled antireflux technique.

Vara/Shanberg Modification (1992) — Urethral-Cecal Anastomosis​

The non-detubularized ileal tail was eliminated and the cecal portion was directly anastomosed to the membranous urethra, removing the tubular ileal segment whose preserved peristalsis contributed to nocturnal incontinence. Overall day + night continence reached 94%, and only 1 of 13 patients with urethral-cecal anastomosis required CIC; the remainder voided by Valsalva with minimal residual.[2]

Bejany/Politano Modification (1993) — Trigone-Like Ureteral Placement​

Twenty-five patients (mean age 61). Ureters were placed in an anatomically correct trigone-like position near the mouth of the neobladder with the left ureter uncrossed, providing easy upper-tract access for surveillance and instrumentation. No vesicoureteral reflux occurred. Daytime continence 100%; nighttime continence 92%. Early complication rate 18%; late complication rate 16%.[3]

Cleveland Clinic Series — Stapled Construction (Kolettis et al., 1996)​

Thirty-eight men, 1990–1995. Approximately 20 cm each of detubularized ileum and cecum. 22 pouches (58%) were fashioned with absorbable staples, significantly simplifying construction. 21 cases (55%) used freely refluxing Bricker ureterointestinal anastomoses; the remainder used tunneled implantation. There was no significant difference in major complication rates between hand-sewn vs stapled groups, no complications related to staple use, and no significant difference between refluxing and tunneled groups for ureteral obstruction or febrile UTI.[4]

B-Bladder — Le Bag with Ileal Chimney (Baniel & Tal, 2004)​

Twenty-nine patients (median follow-up 3.4 years). The Le Bag reservoir was preserved but ureters were anastomosed to a Studer-like isoperistaltic ileal chimney rather than tunneled into the cecum, simplifying ureteral reimplantation. Late complications: recurrent UTI 17%; ureteroenteric stricture 3%. Median survival 71.1 months.[6]

Johns Hopkins Ileocolic Neobladder (Marshall, 1986–1998)​

Twelve-year experience with cecourethral anastomosis for volitional voiding. Early complications 11%; late complications 30%. 76% continent both day and night; 3% nocturnal enuresis only; 15% perform CIC; 3% bothersome daytime stress incontinence; 45% of men potent postoperatively.[5]

Functional Outcomes — Major Series​

SeriesnDaytime ContinenceNighttime ContinenceCIC RateKey Feature
Light & Engelmann 1986[1]4GoodProblematic (nocturnal enuresis)—Original; ileal-tail outlet
Vara/Shanberg 1992[2]1794% (combined day+night)—7.7% (1/13)Urethral-cecal anastomosis
Bejany/Politano 1993[3]25100%92%—Trigone-like ureteral placement; no reflux
Kolettis (Cleveland Clinic) 1996[4]3891%80% (dry or mild)—Stapled construction validated
Johns Hopkins 1986–1998[5]—76% combined day+night3% enuresis only15%12-year experience; 45% potency
B-Bladder (Baniel) 2004[6]29Excellent——Le Bag + Studer-like ileal chimney

Metabolic Outcomes​

Hyperchloremic metabolic acidosis is a recognized consequence of using ileal and colonic segments. In the Cleveland Clinic series, median serum bicarbonate decreased from 28 to 24 mmol/L postoperatively, and the degree of acidosis was directly correlated with pouch length (r = 0.58, p = 0.0002) — longer pouches absorbed more urinary chloride and excreted more bicarbonate.[4] Most cases were mild and did not require treatment, though oral alkalinization can be used when symptomatic. See Urinary Acidifiers & Alkalinizers for management detail.

Randomized Trial — Le Bag vs Ileal Neobladder (Chen et al., 2009)​

The only RCT directly comparing the Le Bag (ileocolonic) with a purely ileal neobladder.[7][8] Single-center, 90 male patients randomized (85 accepted randomization); ileocolonic group 42 patients (33 with complete 6-month follow-up); ileal neobladder group 43 patients (38 complete). The Le Bag arm used a freely refluxing Bricker anastomosis. Primary endpoint: continence and urodynamic parameters at 6 months.

ParameterLe Bag (Ileocolonic)Ileal NeobladderP value
Daytime continence90.9%89.4%NS
Nighttime continence48.5%76.3%Significant (favors ileal)
Neobladder complianceLowerHigher0.05
Initial volumeSimilarSimilarNS
Flow rateSimilarSimilarNS
Maximal urethral pressureSimilarSimilarNS

Conclusions. Daytime continence was equivalent (~90%). Nighttime continence was significantly worse with the Le Bag (RR 0.35, 95% CI 0.15–0.79).[8] The mechanism was lower compliance in the ileocolonic reservoir — despite similar initial volumes, the ileocolonic reservoir generated higher pressures during filling, exceeding relaxed urethral sphincter pressure during sleep.[7] The Cochrane systematic review confirmed that pressure rise during artificial filling was on average higher with ileocolonic neobladder, contributing to nocturnal incontinence.[8]

Complications​

ComplicationIncidence (across series)
Ureteroenteric stricture3–16% (variable by technique)
Urethral stricture3–8%
Recurrent UTI17% (B-Bladder series)
Hyperchloremic metabolic acidosisMild in most; correlated with pouch length
Vesicoureteral reflux0% (Bejany modification) to variable
Pouch calculiReported but uncommon
Nocturnal enuresis3–51.5% (depending on technique and series)

Advantages and Disadvantages​

Advantages

  • Relative ease of construction — simpler than Kock pouch or Hautmann W-neobladder; further simplified with stapled technique.[4]
  • Large, low-pressure reservoir from disrupted peristalsis across two segments.[1]
  • Natural antireflux potential via the ileocecal valve region.[3]
  • Anatomic proximity of cecum/terminal ileum to the pelvis facilitates tension-free urethral anastomosis.
  • Excellent daytime continence — consistently 90–100% across series.[2][3][4][5]
  • Stapled construction validated as safe and time-saving.[4]

Disadvantages

  • Nocturnal incontinence — the dominant weakness; significantly worse than purely ileal neobladders in RCT (48.5% vs 76.3%).[7]
  • Lower compliance than ileal neobladders — colonic component generates higher filling pressures.[7]
  • Hyperchloremic metabolic acidosis correlated with pouch length.[4]
  • Loss of the ileocecal valve — risk of bile-salt malabsorption, diarrhea, and B12 deficiency on long-term follow-up. See Vitamin B12 Supplementation.
  • More complex bowel-segment isolation than purely ileal techniques.
  • Limited comparative data — only one small RCT.[7]

Comparison with Other Neobladders​

FeatureLe BagMainz Pouch IStuderHautmann W
Year introduced1986198519851986
Bowel segmentsTerminal ileum + cecumIleum + cecum + ascending colonIleum onlyIleum only
DetubularizedYesYes (with teniamyotomies)YesYes
Antireflux mechanismTunneled or refluxingSubmucosal tunnel or SLETAfferent limb (indirect)Le Duc or chimney
Daytime continence91–100%90–95%87–93%90–96%
Nighttime continence48.5–94% (variable)79–89%72–79%82–95%
CIC rate7.7–15%5–10%7–10%4–13%
Ileocecal valve sacrificedYesYesNoNo

The Khafagy 2006 RCT comparing ileocecal vs ileal neobladder (60 patients) found similar continence rates between techniques but better renal-unit preservation (93% vs 85%), less residual urine (12 vs 90 mL), and less metabolic acidosis with the ileocecal arm — though that trial used a non-refluxing anastomosis (unlike Chen 2009), which may explain divergent nocturnal continence findings.[10]

Current Status and Legacy​

The Le Bag in its original form is rarely performed today, having been largely superseded by purely ileal neobladders (Studer, Hautmann) which offer superior nighttime continence and avoid sacrifice of the ileocecal valve. The Chen 2009 RCT contributed to this shift.[7]

Legacy contributions:

  1. One of the earliest ileocolonic orthotopic neobladders, demonstrating that combining two different intestinal segments creates a highly compliant low-pressure reservoir.[1]
  2. Established the principle that disrupted directional peristalsis across the ileocecal junction contributes to compliance.[1]
  3. The stapled construction technique demonstrated that absorbable staples could simplify pouch construction without increasing complications — a principle later applied to many other neobladder types.[4]
  4. The B-Bladder modification showed that combining the Le Bag reservoir with a Studer-like chimney could simplify ureteral anastomosis while maintaining excellent results.[6]
  5. The Johns Hopkins experience provided the longest follow-up data for this composite reservoir, confirming durable functional results over 12 years.[5]
  6. The Le Bag concept influenced the development of other ileocecal diversions, including the Mainz Pouch I and various continent cutaneous reservoirs.[11]

Key Takeaways​

  1. The Le Bag is a detubularized ileocolonic neobladder combining terminal ileum and cecum, first described by Light and Engelmann in 1986.[1]
  2. Daytime continence is excellent (91–100%); nocturnal continence was the original technique's main limitation, partially improved by the urethral-cecal anastomosis modification.[2][3][4]
  3. The only RCT (Chen 2009) showed significantly worse nighttime continence (48.5% vs 76.3%) compared to a purely ileal neobladder, attributed to lower compliance in the ileocolonic reservoir.[7]
  4. Hyperchloremic metabolic acidosis is a consistent finding, directly correlated with pouch length.[4]
  5. Rarely used today in its original form, having been superseded by purely ileal neobladders.[7]
  6. The B-Bladder modification (Le Bag + ileal chimney) represents the most refined evolution of the concept.[6]

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):926–30. PMID: 8709366

5. 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

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. 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

9. Marshall FF. "Creation of an Ileocolic Bladder After Cystectomy." J Urol. 1988;139(6):1264–8. doi:10.1016/s0022-5347(17)42885-0

10. 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

11. Wiesner C, Bonfig R, Stein R, et al. "Continent Cutaneous Urinary Diversion: Long-Term Follow-Up of More Than 800 Patients With Ileocecal Reservoirs." World J Urol. 2006;24(3):315–8. doi:10.1007/s00345-006-0078-y