ICONB Principles and Types

Urinary diversion options following radical cystectomy are multiple, evolving and is an area of constant research and innovation. Orthotopic neobladders have always been an attractive option considering their single most ability to provide decent cosmesis despite carrying a higher complication rate and increased operative complexity. To further enhance the benefits that these diversions offer, intracorporeal fashioning was introduced along with preferential utilization of ileal bowel loops owing to their better biochemical stability. All these designs were based on one common principle of creating a low-pressure reservoir utilized detubularised ileum. 

Being a subject of emerging data and research, operative and post operative outcome data is still evolving. With available systemic reviews, the Studer neobladder was the most utilized configuration while the Hautmann W neobladder trailed second.(1)

ICONB configurations

The Hautmann “W” Pouch (2003) – First performed ICONB

The Studer “U” Pouch (2010) – Most frequently performed ICONB

Variant 1 - The Karolinska institute modification (2011)

Variant 2 – The University of Southern California modification (2017)

The Bordeaux “Y” Pouch (2016)

The PADUA Pouch (2018)

Other rarely published Variants 

Camey Pouch (2012)

Pyramid Pouch (2015)

Florence Configuration (FloRIN) (2018)

Vescica Ileale Padovana Pouch (2019)

Shell Reconstruction (2021) 

Juntendo Technique (2025) 

Randomized studies comparing outcomes of Various ICONB designs or ICONB vs Intracorporeal Ileal Conduit (ICIC) are grossly lacking. One systematic review complied the outcomes of ICONB and ICIC based on small retrospective series and concluded that complication rates between both diversions were similar with special mention on many articles carrying apparent selection bias.(2) Bhiryani M et al performed a systematic review comparing ICONB and extracorporeal ONB (ECONB) and concluded that functional outcomes were better with ECONB while perioperative outcomes and complications were better with ICONB.(3)

Principles of ICONB

General Anaesthesia with low lithotomy position and Trendelenburg reduced to 10 degrees after radical cystectomy

6-port pelvic surgery port configuration

Isolation of ileal loop of varying lengths (45 –70cm on an average) for neobladder fashioning harvested 15 to 20 cm distal to ileo-cecal junction

Bowel Detubularisation along the antimesenteric border

Tension free urethro-ileal anastomosis

Folding of detubularised ileal segments to aid in closure and thereby providing characteristic shape to the neobladder

Uretero-neobladder anastomosis on the chimney area of the neobladder

Despite being a complex reconstructive procedure, ICONB continues to attract great attention considering its single most ability to provide excellent cosmesis and maintain decent quality of life. Large, randomized trials on the subject seem to be the need of the hour to arrive at greater insights and proceed towards achieving an ideal standard neobladder design.

by Dr Aravind TK,VMMC & SJH, New Delhi