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Mansoura Neobladder

The Mansoura (Abol-Enein and Ghoneim) neobladder is a detubularized W-shaped ileal orthotopic reservoir with serous-lined extramural tunnels (SLETs) for ureteral implantation. Abol-Enein and Ghoneim reported the technique from Mansoura University, Egypt, in 1994 and a series of 450 patients in 2001. The ureteral implantation method is the defining feature and can also be adapted to other reservoirs.[1][2]

An antireflux effect and preservation of renal function are different outcomes. In a randomized comparison with the T-limb, SLET produced less detected reflux; the Harraz trial found no significant renal-function difference from direct implantation. Patient selection and follow-up are covered in Urinary Diversion Principles.[3][4]

Historical Development​

Ghoneim's Mansoura group reported radical cystectomy for bilharzial (schistosomal) bladder cancer from the 1970s, including 162 patients in 1976.[19]

  • 1994. Abol-Enein and Ghoneim reported two serous-lined extramural tunnels in a detubularized ileal W-bladder in 12 patients. At mean follow-up of 18 months, the examined renal units showed nonobstructed unidirectional flow.[1]
  • 1999. The tunnel principle was extended to a continent cutaneous outlet (serous-lined extramural ileal valve) in 18 men and 5 women. All but one were continent day and night at mean follow-up of 19 months.[14]
  • 2001. The 450-patient neobladder series was published.[2]
  • 2004. Continent cutaneous ileal pouches with serous-lined valves were reported in 109 patients.[15]
  • 2009 and 2014. Randomized trials compared SLET with the T-limb and with direct refluxing implantation (see below).[3][4]
  • 2020. The technique was applied to a bladder-exstrophy patient after complications of colonic diversion.[17]

Reservoir and Tunnel Construction​

Detubularization and reconfiguration aim to provide adequate capacity at low pressure. 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 differ in tunnel length and sequence. 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; Türkölmez made minor modifications for grossly dilated ureters and distal ureteral excision. Papadopoulos reported that the technique was performed with equal or greater ease in dilated ureters.[6][7]

Siracusano placed both ureters in a single right-sided tunnel in 11 men (mean follow-up 12.5 months, no postoperative complications). The authors reported shorter tailoring time and greater anastomotic stability, without a comparison group.[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). Each arm had one stricture. The T-limb is itself an antireflux design and differs from the direct refluxing Studer implantation. Among the 13 refluxing T-limb units, three had significant GFR 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, corrected GFR (MAG3 diuretic scintigraphy) fell significantly in both groups, with no significant difference between techniques.[4] Obstruction occurred in five SLET ureters (4.9%) and one direct refluxing ureter (0.9%), starting 1–7 months after cystectomy.[4] The authors concluded that the need for an antireflux technique should be questioned and tailored to surgeon experience. A 2023 meta-analysis of 11 studies of orthotopic ileal neobladders after cystectomy for bladder cancer found lower pooled odds of vesicoureteral reflux (OR 0.24, 95% CI 0.10–0.59) and higher odds of ureteroenteric stricture (OR 2.84, 95% CI 1.75–4.61) with antireflux versus direct implantation.[22] Renal-function impairment and pyelonephritis did not differ significantly, but the renal estimate was imprecise. The pooled data span several antireflux designs and do not isolate SLET. In subgroup analysis, the stricture association was more apparent when ureteral stents were removed within 14 days.[22]

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.[9]

Unobstructed upper-tract drainage, low-pressure storage, adequate emptying and surveillance are the practical priorities.

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.[2]

FindingReported result
In-hospital deaths4
Early complications42 patients (9%), treated conservatively except three women who required repair of a pouch–vaginal fistula
Oncologic failures90, of which 3 were isolated urethral recurrences
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 separate denominators.[2] The nine women with emptying failure have no stated female evaluable denominator. "Unchanged or improved" upper tracts refers to imaging and not to measured GFR.[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, and urodynamics were available in only 39 patients. Urodynamic findings did not differ significantly.[10]
Papadopoulos 200150 neobladder patients; four unilateral ureteroileal strictures, one unilateral reflux episode, four cases of metabolic acidosisTechnical feasibility in dilated ureters[6]
Türkölmez 200442 patients, mean follow-up 28 months; three refluxing and three strictured renal units, each reported as 3.7%No metabolic complications were observed in this cohort.[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]

Bedük's numbers were ureterointestinal stenosis 5.7% with the Abol-Enein and Ghoneim reservoir versus 10.5% with Mainz, reflux 4.2% versus 7.9%, and nighttime incontinence 8.4% versus 21% (19 Mainz and 36 Mansoura patients). Capacity at 12 months was 442 ± 27 mL versus 426 ± 34 mL.[10]

The early female functional study included 60 women (mean age 48.3 years) with mixed reservoirs: 47 W-neobladders and 13 hemi-Kock pouches. Of 43 followed for mean 20.2 months, 32 were continent day and night, 6 had nighttime incontinence, 2 had daytime stress incontinence and 1 was totally incontinent. Six had difficulty emptying associated with acute urethra–pouch angulation, which the authors attributed to anatomy rather than function. The abstract reports no perioperative mortality and also one fatal postoperative pulmonary embolism.[12]

The later series of 192 women (mean age 50.6 years, mean follow-up 54 months), mostly W-neobladders, reported two deaths from pulmonary embolism and six pouch–vaginal fistulas.[13] Among 177 eligible for functional evaluation, 62 had 75 late complications: reflux 22, ureteroileal stricture 19, stones 18 and chronic pyelonephritis 12. The authors consider close lifelong surveillance mandatory.[13] In a later same-center cohort using mixed orthotopic designs, 31 of 95 women assessed after more than 10 years had chronic retention and 46 of 95 had a greater than 20% decline in renal function from baseline.[23] Disease failures and losses to follow-up were excluded, so these are selected, non-SLET-specific rates.[23]

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 18 men and 5 women. One tapered ileal segment served as the antireflux valve and a second tapered ileal segment or the appendix as the continent outlet; evacuation intervals were 4 to 5 hours.[14]
  • The 2004 cutaneous-pouch series included 109 patients, of whom 93 were evaluable at mean 36.6 months. Forty-four outlets used appendix. Two patients died in hospital of pulmonary embolism. Five evaluable patients were not continent day and night, and late problems included pouch stones (5), stomal stenosis (5) and failure to catheterize (2). Upper tracts were stable or improved in 94.8% of renal units and no patient developed clinical acidosis.[15]
  • Kato applied the principle to 16 neobladders, 10 continent pouches, two ileal ureters with a proximal antireflux mechanism and one total ureteral replacement with colon. The 52 ureters implanted into neobladders or pouches had neither obstruction nor reflux, and 11 continent valves functioned without incontinence. This heterogeneous series shows technical possibilities.[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]

The Antireflux Question: Mansoura and Bern​

The Bern (Studer) experience uses an isoperistaltic afferent limb with direct ureteral implantation and no formal antireflux mechanism. In 482 consecutive patients operated from 1985 to 2005 (447 with an afferent limb), ureteroileal stenosis occurred in 12 of 447 (2.7%). Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction, and patients with normal renal function had no long-term acidosis after 10 years.[20] Both institutions report good upper-tract outcomes with their design. The two series are single-institution and do not compare the designs directly.

Follow-up and Clinical Role​

Counsel about nighttime leakage and the possible need for intermittent catheterization.[21] Emptying dysfunction is a particular concern in women: the EAU 2026 follow-up chapter cites female orthotopic-neobladder data in which approximately two-thirds needed catheterization and nearly 45% did not void spontaneously.[18] Counseling also addresses delayed emptying dysfunction. Follow renal function, metabolic status, reservoir emptying and the upper tracts; investigate new obstruction, infection, stones or continence changes. EAU follow-up guidance advises annual 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).[18]

SLET is one of several ureteral implantation techniques. Ureteral anatomy, reservoir design and surgeon experience guide its use, with attention to obstruction risk.[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.

19. Ghoneim MA, El-Hamady SM, El-Bolkainy MN, Ashamallah AG, Mansour MA, Soliman ES. "Radical Cystectomy for Carcinoma of Bilharzial Bladder. Technique and Results." Urology. 1976;8(6):547–52. doi:10.1016/0090-4295(76)90515-x

20. Studer UE, Burkhard FC, Schumacher M, et al. "Twenty Years Experience With an Ileal Orthotopic Low Pressure Bladder Substitute: Lessons to Be Learned." J Urol. 2006;176(1):161–6. doi:10.1016/S0022-5347(06)00573-8

21. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Bladder Cancer. Version 3.2026. August 6, 2026. Discussion MS-18. Guideline.

22. Zhang Y, Ding H, Zhang Y, et al. "Is Anti-Reflux Anastomosis an Advantage in an Orthotopic Ileal Neobladder? A Systematic Review and Meta-Analysis." Urol Int. 2023;107(1):1-14. doi:10.1159/000525017

23. Zahran MH, Harraz AM, Baset MA, El-Baz R, Shaaban AA, Ali-El-Dein B. "Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women." BJU Int. 2023;132(3):291–297. doi:10.1111/bju.16011