Urinary Diversion Following
Radical Cystectomy
Sia Daneshmand, M.D.
Associate Professor of Surgery
Director of Urologic Oncology
Bladder Cancer
Disease of the elderly- Median age:
69 years in males
71 years in females
Increases directly with age
142/100,000 in men 65-69 years old
296/100,000 in men >85 years old
70,000 cases with over 14,000 deaths in 2010
Patients often have other medical problems
Radical Cystectomy and Urinary Diversion a complex procedure
Requires decision making and extensive counseling regarding treatment
options and diversion choices
Urinary Diversion Options
4 General Types
Ureterosigmoidostomy/ Rectal Reservoir
Ileal Conduit
Continent Cutaneous Pouch (reservoir)
Orthotopic Neobladder
Urinary Diversion at USC
Orthotopic diversion is arguably the gold standard
Every patient undergoing radical cystectomy is consideredfor
an orthotopic diversion, except when one or more
contraindications apply.
SEER- Data
National Cancer Institute (NCI) Surveillance,
Epidemiology, and End Results (SEER) program:
3611 patients who underwent radical cystectomy for
bladder cancer between 1992 and 2000:
20% of patients underwent continent urinary diversion
80% were diverted with an ileal conduit.
SEER Data
Likelihood of continent diversion: (multivariate analysis)
Inversely associated with
older age
African American race
higher comorbidity index
Directly associated with
male sex
higher education level
year of surgery
academic and NCI-designated cancer centers
high-volume providers
Frequency of urinary diversion by continent
reconstruction versus ileal conduit in selected series
Quality of Life Studies
No randomized studies
Difficult to define appropriate criteria
Difficult to develop methodologically sound study designs
to determine which diversion is best
What are the clinical implications of such studies?
Ureterosigmoidostomy
Initially performed in 1850s to divert urine
Continent
Rectal Voiding
Increased risk (40X) of colorectal cancer
Modified Ureterosigmoidostomy
Mainz Pouch II
Ileal Conduit (Urostomy)
Patient/Urinary Diversion Selection
Factors in selection
Patient choice
Surgeon experience/volume
Managing sequela/complications
Patient/Urinary Diversion Selection
Advantages of Ileal Conduit Urinary Diversion
Shorter operative time
Quicker recovery?
Ease of care by others
Disadvantages
Requirement of external appliance
Impairment of body image
Hernia at least 25%
Skin irritation
Patient/Urinary Diversion Selection
Advantages of continent cutaneous urinary diversion
High total (day and night) continence rate
Immediate continence
No need for external appliance
Disadvantages of a continent cutaneous urinary diversion
Need for regular catheterization
Risk for reoperation for complications
Patient/Urinary Diversion Selection
Orthotopic neobladder
Internal pouch created from intestine and anastomosed to the
urethra
Patient/Urinary Diversion Selection
Advantages of Orthotopic Neobladder
Closest to previous way of life
No stoma
Disadvantages of Orthotopic Neobladder
Risk of Urinary Incontinence
Risk of Urinary Hypercontinence
Delayed continence
Urinary Diversion History
History of Neobladders
1950s- Camey
Loop of ileum connected to urethra
1986- Kock Neobladder
Initially devised as reservoir for stool
1993 Kock Neobladder applied to female patients
first perfomed at USC
Contraindications for Orthotopic Neobladder
Compromised renal function (?eGFR limit)
Severe hepatic dysfunction
Compromised intestinal function
Positive urethral margin
Mental impairment
Pre-existing incontinence
Pelvic radiation (increased complications)
Recurrent urethral stricture disease
AGE NOT CONTRAINDICTION!!
Patient/Urinary Diversion Selection
Factors in selection
Safest cancer control
Fewest complications
Easiest adjustment for patient life style
Continence Rates for Orthotopic Neobladders
Authors/Year
No. of
Patients
Mean Follow
Up (months)
Ileal Neobladder
Type
Daytime
Continence* at 1
year (%)
Nighttime
Continence** at 1
year (%)
Hautmann et
al./1999
363
57
Hautmann
92
71
Steven et al./2000
166
32 (Median)
Kock
98
75
Abol-Enein et
al./2001
344
38
Hautmann
93
80
Lee et al./2003
130
20
Studer
93/Hautmann
37
87
72
Stein et al./2004
209
33 (Median)
T-Pouch
87***
72***
Studer et al./2006
482
32 (Median)
Studer
92
79
* Daytime continence defined as Complete or Good
** Nighttime continence defined as Complete or Good
*** F/u period not reported
Continence Rates for Orthotopic Neobladders
Authors/Year
No. of
Patients
Mean Follow
Up (months)
Ileal Neobladder
Type
Daytime
Continence* at 1
year (%)
Nighttime
Continence** at 1
year (%)
Hautmann et
al./1999
363
57
Hautmann
92
71
Steven et al./2000
166
32 (Median)
Kock
98
75
Abol-Enein et
al./2001
344
38
Hautmann
93
80
Lee et al./2003
130
20
Studer
93/Hautmann
37
87
72
Stein et al./2004
209
33 (Median)
T-Pouch
87
72
Studer et al./2006
482
32 (Median)
Studer
92
79
* Daytime continence defined as Complete or Good
** Nighttime continence defined as Complete or Good
Continence Rates for Orthotopic Neobladders
Authors/Year
No. of
Patients
Mean Follow
Up (months)
Ileal Neobladder
Type
Daytime
Continence* at 1
year (%)
Daytime Pad-Free (%)
Hautmann et
al./1999
363
57
Hautmann
92
64
Steven et al./2000
166
32 (Median)
Kock
98
81
Abol-Enein et
al./2001
344
38
Hautmann
93
NR
Lee et al./2003
130
20
Studer
93/Hautmann
37
87
67
Stein et al./2004
209
33 (Median)
T-Pouch
87
87
Studer et al./2006
482
32 (Median)
Studer
92
NR
Continence and Complications with
Orthotopic Neobladders
Continence
Daytime:
87-98% at 1pad or less
64-87% pad free
Nighttime: 71-80% at 1pad or less
Complication Rates
Early: 14-39%
Late: 10-55%
Patient/Urinary Diversion Selection
Patient must ultimately weigh the given risks and benefits
based on:
Lifestyle
Motivation
Priorities
Physiology of Neobladder
Goal to replicate bladder physiology
High volume, low pressure storage
Empty completely
Continent
Protect kidneys
Safe
Maintain normal body image
Types of Neobladders
Camey I & II
Hautman
Kock
Mainz
T-Pouch, Florida, UCLA, S pouch, Le bag
Studer (most common)
Elderly Patient Population
September 2004 to July 2009
230 patients underwent radical cystectomy with
urinary diversion at OHSU by single surgeon
(SD)
137 male patients underwent an orthotopic ileal
neobladder.
Continence Scoring
Each patient was assigned a daytime and nighttime continence score:
SCORE
CRITERIA
Completely dry without use of a pad
Leakage 2 x per week, pad for safety
3
4
No more than 1 pad per day
More than 1 pad per day
Social continence 2.0
Age and Continence
n=111
Average Age: 67 +/- 10 (range: 42-88)
Mean daytime continence score
<70
>70
1.4
1.5
Mean nighttime continence score
<70
>70
1.8
1.9
Orthotopic Neobladder
Studer Pouch
22 cm
22 cm
15 cm
(afferent
limb)
Studer Pouch
Folding Pouch
Completed Pouch
Urethral
Anastamosis
Afferent Limb
Neobladder-urethral anastamosis
Catheter
Quality of Life Studies
Multiple quality of life instruments are available
but most lack specific attention to the nuances of
urinary diversion.
Comparing QOL in patients with conduit
diversions versus orthotopic diversions, only one
study showed a superior QOL for orthotopic
diversions, however a true test of superiority
is not possible due to patient variation in body
image and expectation.
Quality of Life
Neobladder
Given no info on various
65%
Ileal Conduit
71%
types of options
Completely satisfied with
the extent of info and the
manner in which it was given
91%
79%
Recommend to friend
97%
36%
Quality of Life
Neobladder
Ileal Conduit
Leisure activity reduced
8.7%
36%
Travel activity reduced
22%
52%
Number of friendships
Reduced
4%
15%
Changes in daily life
29%
73%
Hobisch A, et al. Quality of life after cystectomy and orthotopic neobladder
versus ileal conduit urinary diversion. Worl J Urol (2000) 18: 338-344.
Voiding
Neobladder volumes 250cc- 1000cc
Increases with time
Residual volume usually less than 100cc
Requires abdominal straining/ pelvic floor relaxation to void
Continent Cutaneous Diversion
Indications
Urinary Incontinence
Urethral stricture
Positive urethral margin
? Prior Pelvic Radiation
Continence Mechanism
Ileocecal Valve (Indiana Pouch)
Tapered Ileum
Appendix (buried in subserosal tunnel)
Continence Rates with Continent Cutaneous Urinary Diversions
Authors
Year
No.
Pts
Mean
Follow Up
(mos)
Urinary
Diversion
Type
Daytime and Nighttime
continence (%)
Bihrle R
1997
50
30
(minimum)
Indiana
94
Stein et
Daneshmand
2004
27
33
Penn
100
Wiesner et al.
2006
401
95
Mainz
I/Right
Colon
87
Holmes et al.
2002
125
41
Indiana
72
Webster et al.
2003
74
133
Florida
93
Complication Rates with Continent Cutaneous Urinary Diversion
Authors
Year
No.
Pts
Follow Up
(mos)
Urinary
Diversion
Type
Complication
Requiring
Surgical
Intervention (%)
Stomal
Complications (%
of total patients)
Bihrle R
1997
50
30
(minimum)
Indiana
18
Stein et
Daneshmand
2004
27
33 (mean)
Penn
33
28
Wiesner et al.
2006
401
95 (mean)
Mainz
I/Right
Colon
> 51
36
Holmes et al.
2002
125
41
Indiana
52
14
Webster et al.
2003
74
133
Florida
39
12
Continence and Complications with
Continent Cutaneous Urinary Diversion
Continence
Complete Continence: 72-100%
Complications Requiring Reoperation
18-52%
Primarily stomal revisions, ureteral revisions, and pouch stones
Conclusion
Excellent outcomes with urinary diversion at centers of
excellence
Orthotopic neobladder arguably the gold standard form
of diversion
Patients who are not candidates for orthotopic
neobladder can be offered continent cutaneous forms of
diversion provided they have no contraindication
Future
Improving sexual function with radical surgery
Decreasing Complication rates
Improving continence
