What determines the optimal urinary diversion?

Schuckman is an associate professor of urology/urologic oncology at the Keck School of Medicine of the University of Southern California in Los Angeles.

Anne K. Schuckman, MD

Patients undergoing radical cystectomy are confronted with not only the prospect of cancer, chemotherapy and major surgery but also with choosing a type of urinary diversion. Most patients have never heard of a urinary diversion, nor do they have any experience to help them choose which life-altering reconstruction will be best for them. As clinicians, we are tasked with counseling patients to help them make the best choice, often in a short period of time. Often, this counseling is also the first time we have met the patient.

Unfortunately, we know that, according to the National Cancer Database, up to 88% of all diversions in the US are noncontinent as of 2015.^1,2 Conversely, most patients express that if they have the choice, they would prefer a continent diversion. It is unclear what is driving this discrepancy, but it does not seem to entirely be patient choice. I believe it is incumbent on urologists to approach diversion counseling from a holistic perspective to help match a patient with the choice that feels right to them. When counseling patients, I use the following framework to guide the discussion of diversion.

Disease factors

Most of the time, tumor location will not influence available diversion types. While prostatic urethral involvement in men and bladder neck involvement in women may predict a higher likelihood of urethral involvement,^3,4 I use the intraoperative frozen section of the urethral margin to make a final determination of eligibility for neobladder.^5-7 In the setting of high-grade invasive disease on a frozen section, I do not perform an orthotopic diversion and would opt for a cutaneous option.

In women, a high-volume tumor in the trigone or posterior bladder with palpable mass may lead to resection of the anterior vaginal wall. However, several studies have demonstrated that even in these situations, preservation of some or all female pelvic organs is usually feasible, and preservation is not related to tumor recurrence or positive margin.^4,8 Resection of the anterior vaginal wall may correlate with a higher risk of neobladder-vaginal fistula if a neobladder is formed,⁹ but an omental flap can limit this risk to a rate of approximately 5%. I counsel patients on the small risk of neobladder-vaginal fistula and discuss that continent cutaneous diversion would eliminate this risk. In men, urethral stricture disease may preclude orthotopic diversion. In general, prostatic urethral involvement alone or carcinoma in situ (CIS) on the frozen section of the urethra would not exclude orthotopic diversion.⁷

Physiological Factors

Continent diversion is known to be associated with long-term electrolyte imbalances, such as hypokalemic, hyperchloremic metabolic acidosis.⁸ Patients with preoperative chronic kidney disease and an estimated glomerular filtration rate of lower than 40¹⁰ may be at higher risk of long-term metabolic issues and worsening renal functional decline with continence diversion. These patients may be best served by an ileal conduit.

Patients with underlying bowel issues such as Crohn’s disease or ulcerative colitis may be excluded as candidates for diversions requiring segments of the colon or long segments of small bowel. Patients with underlying cirrhosis or liver dysfunction are likely at risk for major metabolic disturbance with any form of diversion utilizing the bowel. In these extreme situations, cutaneous ureterostomies may be considered if feasible.

Patient Factors and Preference

Although tumor-related or metabolic issues are more objective, the most important factors in helping patients choose a diversion are usually more subjective and personal. Thus, it is important to complete a meticulous history and physical, delver into a patient’s lifestyle and goals and explain the options thoroughly to effectively counsel a patient.

Understanding a patient’s preoperative continence is vital. Many patients will present with incontinence that is related to the recent transurethral resection of the bladder tumor, underlying tumor factors, widespread cis, or poorly functioning bladder due to intravesical therapy or prior radiation. In these cases, removing the bladder will eliminate the incontinence related to “bladder function” and should not influence diversion choice. In women with long-standing stress urinary incontinence (SUI), I do not recommend an orthotopic diversion. However, for men—even those with mild SUI or prior pelvic radiation—it is appropriate to discuss neobladder, with the understanding that a patient may require an artificial urinary sphincter at a later date.

For women, it is important to discuss the risk of needing to perform clean intermittent catheterization (CIC) of a neobladder. Although the data on hypercontinence are variable, in most studies, the range of the need for CIC is between 20% and 40%.^11,12 If women are not willing to consider catheterization of the urethra, I generally do not recommend a neobladder. Similarly, if a patient’s body habitus, hand function, or overall mental and physical functional status do not suggest that they can catheterize independently on a schedule, I do not recommend any form of continent diversion.

Conversely, in men, obesity may favor a neobladder rather than a stoma, which carries a higher risk of parastomal hernia.¹³ Additionally, there is only a 2% to 20% risk of retention and need for self-catheterization in men. Patients with hand issues may have severe challenges with precisely cutting and changing appliances and may enjoy more independence with a neobladder.

Finally, most patients worry about completing routine activities, sleeping, and traveling with a urinary diversion. I reassure patients that they will have no limitations in their lifestyle with any of the forms of urinary diversion. For patients whose main form of exercise is a water sport, we do discuss that a continent diversion may be more practical than a stoma.

Tools

At the time of initial consultation, many patients are on information overload with discussions about their cancer care as well as the myriad of considerations for choosing the proper diversion. During the initial consultation, I provide written information and drawings of the various diversions,. as well as the Bladder Cancer Advocacy Network’s (BCAN) excellent “Bladder Cancer Basics” book.¹⁴ Patients and caregivers are strongly encouraged to attend a preoperative Zoom educational session with our bladder cancer team, which is led by the enterostomal nurses and includes other peri-op team members such as pelvic floor physical therapists and nutritionists. Many patients have expressed that connecting with other patients directly through either BCAN’s Survivor to Survivor network or through individually matched patients from our own practice provides invaluable support and practical advice.There are also several tools available for supporting patient decision-making offering pictoral representations of complications.¹⁵

Conclusions

Ultimately, there is no “right choice” when it comes to urinary diversion. Because of the irreversibility of a diversion, most patients have only experienced one type of reconstruction, and have no basis for cross comparisons. Moreover, the literature suggests that patients are generally satisfied with their choice.^16-18 It is up to providers to help the patient understand their options and the possible long-term complications of whichever urinary diversion type they choose without the overlay of our own preferences and biases. Moreover, it is incumbent on faculty surgeons to teach our trainees multiple forms of diversion so that choice is preserved for patients requiring diversion in the future.²

REFERENCES

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2. Gore JL, Yu HY, Setodji C, et al; Urologic Diseases in America Project. Urinary diversion and morbidity after radical cystectomy for bladder cancer. Cancer. 2010;116(2):331-339. doi:10.1002/cncr.24763

3. Stein JP, Esrig D, Freeman JA, et al. Prospective pathologic analysis of female cystectomy specimens: risk factors for orthotopic diversion in women. Urology. 1998;51(6):951-955. doi:10.1016/s0090-4295(98)00099-5

4. Gregg JR, Emeruwa C, Wong J, et al. Oncologic outcomes after anterior exenteration for muscle invasive bladder cancer in women. J Urol.2016;196(4):1030-1035. doi:10.1016/j.juro.2016.04.090

5. Gakis G, Schmid MA, Hassan F, Stenzl A, Renninger M. The accuracy of sequential urethral frozen section and its impact on urethral recurrence after radical cystectomy. Clin Genitourin Cancer. 2022;20(5):e390-e395. doi:10.1016/j.clgc.2022.04.007

6. Laukhtina E, Moschini M, Soria F, et al. Follow-up of the urethra and management of urethral recurrence after radical cystectomy: a systematic review and proposal of management algorithm by the European Association of Urology-Young Academic Urologists: Urothelial Carcinoma Working Group. Eur Urol Focus. 2022;8(6):1635-1642. doi:10.1016/j.euf.2022.03.004

7. Stein JP, Clark P, Miranda G, Cai J, Groshen S, Skinner DG. Urethral tumor recurrence following cystectomy and urinary diversion: clinical and pathological characteristics in 768 male patients. J Urol.2005;173(4):1163-1168. doi:10.1097/01.ju.0000149679.56884.0f

8. Djaladat H, Bruins HM, Miranda G, Cai J, Skinner EC, Daneshmand S. Reproductive organ involvement in female patients undergoing radical cystectomy for urothelial bladder cancer. J Urol. 2012;188(6):2134-2138. doi:10.1016/j.juro.2012.08.024

9. Rosenberg S, Miranda G, Ginsberg DA. Neobladder-vaginal fistula: the University of Southern California experience. Neurourol Urodyn. 2018;37(4):1380-1385. doi:10.1002/nau.23454

10. Sperling CD, Lee DJ, Aggarwal S. Urinary diversion: core curriculum 2021. 2021;78(2):293-304. doi:10.1053/j.ajkd.2020.12.023

11. Murray KS, Arther AR, Zuk KP, Lee EK, Lopez-Corona E, Holzbeierlein JM. Can we predict the need for clean intermittent catheterization after orthotopic neobladder construction? Indian J Urol. 2015;31(4):333-338. doi:10.4103/0970-1591.166460

12. Clifford TG, Shah SH, Bazargani ST, et al. Prospective evaluation of continence following radical cystectomy and orthotopic urinary diversion using a validated questionnaire. J Urol. 2016;196(6):1685-1691. doi:10.1016/j.juro.2016.05.093

13. Ghoreifi A, Allgood E, Whang G, et al. Risk factors and natural history of parastomal hernia after radical cystectomy and ileal conduit. BJU Int. 2022;130(3):381-388. doi:10.1111/bju.15658

14. Bladder Cancer Advocacy Network handout. Bladder Cancer Advocacy Network. Accessed December 9, 2024. https://bcan.org/bladder-cancer-basics-handbook/

15. McAlpine K, Lavallée LT, Stacey D, et al. Development and acceptability testing of a patient decision aid for urinary diversion with radical cystectomy. J Urol. 2019;202(5):1001-1007. doi:10.1097/JU.0000000000000341

16. Check DK, Leo MC, Banegas MP, et al. Decision regret related to urinary diversion choice among patients treated with cystectomy. J Urol. 2020;203(1):159-163. doi:10.1097/JU.0000000000000512

17. Kern SQ, Speir RW, Tong Y, et al. Longitudinal health related quality of life after open radical cystectomy: comparison of ileal conduit, Indiana pouch, and orthotopic neobladder. Urology. 2021;152:184-189. doi:10.1016/j.urology.2020.12.036

18. Porter MP, Penson DF. Health related quality of life after radical cystectomy and urinary diversion for bladder cancer: a systematic review and critical analysis of the literature. J Urol.2005;173(4):1318-1322. doi:10.1097/01.ju.0000149080.82697.65