The major motivation in patients with a conversion from incontinent to continent diversion was dislike of the initial UD. Overall nine male and three female patients in the Hautmann series [5] underwent conversion to an OBS. In seven patients the underlying disease was non-oncologic, and the other five had UC but had no evidence of disease for 1 year. In three of the male patients, the apex/prostate had been left behind at RC. Of the three female patients, two underwent cystectomy at the second UD. In the other six male and female patients, the urethra and the striated sphincter were spared during cystectomy, but the urethral remnant had been closed.

All patients were informed about the risk of postoperative hypercontinence (requiring clean intermittent catheterization) or incontinence. In patients with remnants of the prostate, resection of the residual prostatic tissue was performed without any problems. In a case of an ileal conduit, we left the ureterointestinal anastomoses intact and incorporated this intestinal segment in the neobladder as an afferent tubular segment and part of the lateral wall [5] (See Fig. 12.1)

In the long term, all female patients experienced hypercontinence [5]. All men with initial complete resection of the prostate and closure of the urethral remnant experienced subneovesical obstruction and underwent transurethral resection of the neovesicourethral anastomosis, or performed clean intermittent catheterization. Male patients who had at least remnants of the prostate had excellent functional long-term results [2]. The results from the series described by Hautmann et al. [5] are consistent with the USC experience [2].

The precision of the anastomosis to the urethra and the presence of a retained apex of the prostate were major factors in the technical success of the operation, degree of continence, and satisfaction of the patients. All four patients who had some portion of retained prostate enjoy excellent continence without anastomotic stricture. In two of the early undiversion patients with direct membranous urethral anastomoses, strictures occurred, and they subsequently chose to proceed with continent cutaneous diversion. The other five patients with anastomoses to the membranous urethral stump did well, but two required an artificial urinary sphincter for continence. These latter five patients had more extensive pelvic mobilization of the urethra for more precise anastomoses. The satisfaction level of all nine continuing neobladder patients, even if an artificial urinary sphincter was necessary, has been exceptional [2].

An occasional bladder cancer patient will have undergone cystoprostatectomy with an inadvertent portion of the prostatic urethra left intact. Many patients with a history of a neurogenic bladder or congenital urinary tract anomalies have undergone cutaneous diversion with only simple cystectomy. These men are ideal candidates for undiversion because the remaining apex of the prostate allows the urethral anastomosis to be performed well above the urogenital diaphragm, and in all four of our cases, a satisfactory anastomosis was accomplished, and good continence has been achieved. These patients must be aware, however, that they are still at risk for prostate cancer in the remaining prostate apex and must continue to be followed with prostate-specific antigen levels and examination.