Skip to main content

Mansoura Neobladder

The Mansoura (Abol-Enein–Ghoneim) neobladder is a detubularized W-shaped ileal orthotopic reservoir with serous-lined extramural tunnels (SLETs) for ureteral implantation. The initial clinical technique was reported in 1994; a later series included 450 patients. Its defining feature is the method of ureteral implantation, which can also be adapted to other reservoirs.[1][2]

An antireflux effect and preservation of renal function are different outcomes. SLET can reduce radiographic reflux, but randomized evidence does not establish that it is essential for renal protection in every orthotopic neobladder. Patient selection and follow-up belong to the Urinary Diversion Principles.[3][4]

Reservoir and Tunnel Construction​

Detubularization and reconfiguration aim to provide adequate capacity at low pressure; a W shape does not guarantee compliance or efficient emptying. Bowel length and mesenteric reach must allow a dependent, tension-free urethral outlet without compromising perfusion.[2][5]

The operative distinction is a trough formed between adjacent ileal limbs, not a dissected serosa-only flap.[1][5]

  1. Isolate suitable ileum, restore bowel continuity and open the reservoir segment along its antimesenteric border.
  2. Arrange the detubularized bowel in a W. Suture the medial portions to form the reservoir plate while preserving the lateral portions needed for the tunnels.
  3. Approximate adjacent lateral limbs with seromuscular sutures, creating a serosa-lined trough. The serosa is the lining of this space; it is not elevated as an independent flap.
  4. Position the well-perfused ureter without tension or angulation. Spatulate it and perform the ureteral-mucosa-to-intestinal-mucosa anastomosis at the tunnel outlet.
  5. Close the overlying bowel edges to enclose the ureter within the extramural tunnel, preserving unobstructed drainage.
  6. Complete the reservoir and dependent urethral anastomosis according to the chosen sequence, with appropriate drainage and leak assessment.[5]

Published configurations and modifications use different lengths and sequences; there is no universal 3–4 cm serosal-incision recipe. A tight tunnel can obstruct a ureter, and an antireflux design does not compensate for ischemia, tension or poor reservoir emptying.[4]

SLET avoids ureteral submucosal tunneling and ileal nipple intussusception, but it still includes a mucosa-to-mucosa urinary anastomosis. Small external series describe its feasibility in dilated ureters or after distal ureteral excision. These observations do not prove equal results for all ureteral diameters or make tailoring unnecessary in every case.[6][7]

Siracusano described placing both ureters in a single right-sided tunnel in 11 men. The authors proposed simpler construction, but this preliminary report did not establish a comparative operating-time or anastomotic-stability advantage.[8]

Randomized Evidence on Reflux and Renal Function​

SLET versus the T-limb: Osman 2009​

Sixty patients were randomized. Long-term assessment included 27 patients/49 renal units with SLET and 23 patients/45 units with the T-limb. Mean follow-up was 6.3 and 7.4 years, respectively.[3]

Outcome among evaluated renal unitsSLETT-limb
Ureteroileal stricture1/491/45
Reflux on ascending study0/4913/45 (29%)
Progressive cortical scarring, with or without a substantial GFR reduction3 units4 units

SLET produced less detected reflux (p < 0.01). One stricture in each arm does not prove equivalent obstruction risk, and the small renal-unit outcomes do not establish overall renal superiority. The T-limb is itself an intended antireflux design; it should not be mislabeled as the direct refluxing Studer implantation. Among the 13 refluxing T-limb units, three had significant GFR deterioration; that subgroup association does not prove reflux caused the deterioration.[3]

SLET versus direct refluxing implantation: Harraz 2014​

This prospective randomized study included 102 patients, with the two ureters in each patient assigned to different implantation methods. At median six-year follow-up, there was no observed between-technique difference in the decline of the reported scintigraphy-derived renal-function measure. Obstruction occurred on five SLET sides versus one direct-refluxing side. This supports tailoring the anastomosis rather than assuming an antireflux tunnel is necessary for renal preservation; it is not proof that the techniques are equivalent for every clinical outcome.[4]

The larger USC-STAR trial provides complementary evidence: 484 patients were randomized to orthotopic T-pouch or Studer reconstruction. It did not demonstrate a three-year renal-function benefit from the T-pouch antireflux mechanism and found more diversion-related secondary interventions. It tested a different tunnel design, so its results should not be substituted for a direct SLET comparison.[9]

For practice, prioritize unobstructed upper-tract drainage, low-pressure storage, adequate emptying and surveillance. Reflux seen on a pouchogram is one finding; its absence is not a complete assessment of renal safety.

The 450-Patient Mansoura Series​

Abol-Enein and Ghoneim reported 353 men and 97 women undergoing radical cystectomy with W-neobladder reconstruction. 344 were evaluable, at mean follow-up 38 ± 25 months. This is a substantial historical cohort, but not complete long-term follow-up of all 450 patients.[2]

FindingReported result
In-hospital deaths4
Early complications42 patients; three women required repair of a pouch–vaginal fistula
Daytime/nighttime continence93.3% / 80%
Upper tracts unchanged or improved96.2% of reimplanted renal units
Reflux3% of renal units
Selected late complications10 pouch stones, 11 outflow obstructions, two mucus-retention events, three adhesive bowel obstructions; nine women had emptying failure described as hypercontinence

Patient counts, evaluable subsets and renal units are distinct denominators. In particular, the nine women with emptying failure should not be converted into a universal 9.3% female catheterization risk using the full initial female cohort. Unchanged imaging also should not be relabeled as a measured GFR benefit.[2]

External and Female Experience​

StudyPopulation and useful findingImportant limit
Bedük 200336 ileal AG and 19 ileocecal Mainz neobladders; median follow-up 31 and 36 monthsNonrandomized comparison. Nighttime incontinence was defined as at least twice weekly; numerically fewer events with AG do not prove superiority. Urodynamics were available in only 39 patients.[10]
Papadopoulos 200150 neobladder patients; four unilateral ureteroileal strictures, one unilateral reflux episode, four cases of metabolic acidosisTechnical feasibility in dilated ureters does not imply freedom from metabolic or obstructive complications.[6]
Türkölmez 200442 patients, mean follow-up 28 months; three refluxing and three strictured renal units, each reported as 3.7%These are renal-unit rates, not patient rates. No observed metabolic complications in this cohort does not exclude a later risk.[7]
Wiesner 2007Retrospective Mainz I cutaneous-diversion study: 458 patients, 809 submucosal and 74 SLET renal units; median follow-up 89 monthsObserved obstruction was 7.3% versus 4.1%, with a favorable SLET signal in dilated upper tracts. Different group sizes, selection and a different reservoir prevent treating this as randomized Mansoura-neobladder superiority.[11]

The early female functional study included 60 women with mixed reservoirs: 47 W-neobladders and 13 hemi-Kock pouches. Of 43 followed for mean 20.2 months, 32 were reported continent by day and night. Six had difficulty emptying associated with acute urethra–pouch angulation. A postoperative fatal pulmonary embolism was reported, so the study should not be summarized as having no postoperative mortality.[12]

The later 192-woman series, mostly W-neobladders, reported two deaths from pulmonary embolism and six pouch–vaginal fistulas. Among 177 eligible for functional evaluation, 62 experienced 75 late complications. This demonstrates the need for continuing follow-up; it does not provide a universal female complication rate independent of the operative technique and follow-up period.[13]

The tunnel concept can also support a continent catheterizable outlet, but these reconstructions must be distinguished from an orthotopic neobladder:

  • The 1999 outlet report included 23 patients and used tapered ileum or appendix for the efferent channel.[14]
  • The 2004 cutaneous-pouch series included 109 patients, of whom 93 were evaluable at mean 36.6 months. Forty-four outlets used appendix. Five evaluable patients were not continent day and night; late problems included stones, stenosis and inability to catheterize.[15]
  • Kato described applications to neobladders, cutaneous pouches and ureteral replacement in a small heterogeneous experience; this establishes technical possibilities rather than universal applicability.[16]
  • The 2020 pediatric exstrophy report used an appendix channel and an afferent ileal segment within serosa-lined tunnels after complications of colonic diversion. It remains a single-case technique report.[17]

Follow-up and Clinical Role​

Counsel about nighttime leakage and the possible need for intermittent catheterization, including delayed emptying dysfunction. Follow renal function, metabolic status, reservoir emptying and the upper tracts; investigate new obstruction, infection, stones or continence changes. EAU recommends annual B12 measurement after cystectomy with bowel diversion.[18]

The SLET is a useful reconstructive option. Its use should reflect the ureteral anatomy, reservoir design and the surgeon's experience, with explicit attention to the risk of obstruction. Neither historical favorable continence percentages nor lower radiographic reflux justify declaring it the best neobladder or an obligatory antireflux mechanism.[3][4]

See Also​

References​

1. Abol-Enein H, Ghoneim MA. "A Novel Uretero-Ileal Reimplantation Technique: The Serous Lined Extramural Tunnel. A Preliminary Report." J Urol. 1994;151(5):1193–7. doi:10.1016/s0022-5347(17)35211-4

2. Abol-Enein H, Ghoneim MA. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol. 2001;165(5):1427–1432. doi:10.1016/S0022-5347(05)66322-7. PMID:11342891.

3. Osman Y, Abol-Enein H, El-Mekresh M, et al. "Comparison Between a Serous-Lined Extramural Tunnel and T-Limb Ileal Procedure as an Antireflux Technique in Orthotopic Ileal Substitutes: A Prospective Randomized Trial." BJU Int. 2009;104(10):1518–21. doi:10.1111/j.1464-410X.2009.08574.x

4. Harraz AM, Mosbah A, Abdel-Latif M, et al. Impact of the type of ureteroileal anastomosis on renal function measured by diuretic scintigraphy: long-term results of a prospective randomized study. BJU Int. 2014;114(2):202–209. doi:10.1111/bju.12511.

5. El-Helaly HA, Saifelnasr MK, Mohamed KM, Abdelaziz AS, Youssof HA. Outcome of orthotopic sigmoid versus ileal neobladder reconstruction. Urol Ann. 2019;11(2):204–210. doi:10.4103/UA.UA_137_18. Operative methods used here to clarify trough construction, not comparative superiority.

6. Papadopoulos I, Weichert-Jacobsen K. "Experiences With the Entero-Ureteral Anastomosis via the Extramural Serous-Lined Tunnel: Procedure of Abol-Enein." Urology. 2001;57(2):234–8. doi:10.1016/s0090-4295(00)00904-3

7. Türkölmez K, Baltaci S, Göğüş C, Bedük Y, Göğüş O. "Results of the Ureteral Reimplantation With Serous-Lined Extramural Tunnel in Orthotopic Ileal W-Neobladder." Int J Urol. 2004;11(6):368–73. doi:10.1111/j.1442-2042.2004.00807.x

8. Siracusano S, Liguori G, Trombetta C, d'Aloia G, Belgrano E. "Modified Ghoneim's Technique Using a Single Serous-Lined Extramural Tunnel in Detubularized Orthotopic Ileal W-Bladder." Eur Urol. 2000;38(3):313–5. doi:10.1159/000020299

9. 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.

10. Bedük Y, Türkölmez K, Baltaci S, Göğüş C. "Comparison of Clinical and Urodynamic Outcome in Orthotopic Ileocaecal and Ileal Neobladder." Eur Urol. 2003;43(3):258–62. doi:10.1016/s0302-2838(03)00042-3

11. Wiesner C, Pahernik S, Stein R, et al. "Long-Term Follow-Up of Submucosal Tunnel and Serosa-Lined Extramural Tunnel Ureter Implantation in Ileocaecal Continent Cutaneous Urinary Diversion (Mainz Pouch I)." BJU Int. 2007;100(3):633–7. doi:10.1111/j.1464-410X.2007.06991.x

12. Ali-el-Dein B, el-Sobky E, Hohenfellner M, Ghoneim MA. Orthotopic bladder substitution in women: functional evaluation. J Urol. 1999;161(6):1875–1880. doi:10.1016/S0022-5347(05)68832-5. PMID:10332457.

13. Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, et al. "Surgical Complications Following Radical Cystectomy and Orthotopic Neobladders in Women." J Urol. 2008;180(1):206–10; discussion 210. doi:10.1016/j.juro.2008.03.080

14. Abol-Enein H, Ghoneim MA. Serous lined extramural ileal valve: a new continent urinary outlet. J Urol. 1999;161(3):786–791. doi:10.1016/S0022-5347(01)61769-5. PMID:10022685.

15. Abol-Enein H, Salem M, Mesbah A, et al. "Continent Cutaneous Ileal Pouch Using the Serous Lined Extramural Valves. The Mansoura Experience in More Than 100 Patients." J Urol. 2004;172(2):588–91. doi:10.1097/01.ju.0000129437.33688.4d

16. Kato H, Kiyokawa H, Igawa Y, Nishizawa O. "The Serous-Lined Tunnel Principle for Urinary Reconstruction: A More Rational Method." BJU Int. 2001;87(9):783–8. doi:10.1046/j.1464-410x.2001.02229.x

17. Abdelhalim A, Soltan MA, Helmy TE, Dawaba ME, Hafez AT. "Ileal Neobladder With a Continent Cutaneous Catheterizable Channel Using the Extramural Serous Lined (Mansoura) Technique in a Bladder Exstrophy Patient." Urology. 2020;146:302. doi:10.1016/j.urology.2020.09.021

18. European Association of Urology. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. 2026. Follow-up, section 7.4. Guideline.