Elsevier

European Urology

Volume 53, Issue 4, April 2008, Pages 834-844
European Urology

Reconstructive Urology
Urinary Diversions after Cystectomy: The Association of Clinical Factors, Complications and Functional Results of Four Different Diversions

https://doi.org/10.1016/j.eururo.2007.09.008Get rights and content

Abstract

Purpose

We present a single institute experience of the four most widely used diversions after cystectomy in 281 patients, with an evaluation of the association between clinical factors, complication rates, functional results, and metabolic complications.

Materials and methods

Between 1990 and 2005, 281 consecutive cystectomies were performed at our institute. Four different diversions were offered: an ileal conduit according to Bricker (IC; 118 patients), an Indiana pouch (IP; 51 patients), and orthotopic diversions after cystectomy/neobladder (N; 62 patients), or sexuality-preserving cystectomy and neobladder (SPCN; 50 patients).

Results

Forty-four percent developed early complications: IC 48%, IP 43%, N 42%, and SPCN 38%. High ASA score was the only variable significantly associated with early major complications (ASA 1 vs. 3: HR, 0.32; 95%CI, 0.14–0.72). Late complication rate was 51% with fewer complications in the IC group, IC 39%, IP 63%, N 59%, and SPCN 60% (HR, 0.32; 95%CI, 0.14–0.72), which was explained by fewer uncomplicated urinary tract infections (one third of all late complications) in the IC group. There were no differences in experienced late major complications. We found no significant association between tumour stage, ASA, age, preoperative radiotherapy, gender, and diversion-related complication rates.

Complete daytime and nighttime continence, respectively, was achieved in 96% and 73% after IP, 90% and 67% after neobladder, and 96% and 67% after SPCN. Metabolic changes were found in 24% of the patients: 21% after IC, 26% after IP, and 28% after orthotopic diversion (neobladder and SPCN combined); low vitamin B12 was measured in 23%, 15%, and 15% respectively.

Conclusions

Cystectomy with any subsequent diversion remains a procedure with considerable morbidity. High ASA score was associated with more early complications. Orthotopic diversions provide good functional results, but at the cost of more late complications compared with ileal conduits. We found no evidence that age, ASA score, positive lymph nodes, extravesical tumour growth, or previous radiotherapy were contraindications per se for any diversion.

Introduction

Radical cystectomy with a urinary diversion is still considered the gold standard for muscle-invasive and refractory superficial bladder cancer. Different techniques and types of urinary diversions have been presented. The recent debate on cystectomy versus radiotherapy in the elderly underlines the controversies related to age and ASA score in surgery, and controversies exist on whether any type of diversion can be used in any patient [1], [2]. Many considerations determine the final choice of urinary diversion in the individual patient; it should be oncologically safe and technically feasible and secure, provide good functional results, and comply with the patient's choice if possible. Some investigators advocate against the use of an orthotopic diversion after previous radiotherapy or in advanced stages of disease, whereas these factors are not exclusion criteria for others [3], [4]. A urinary diversion should allow sufficient urinary flow without compromising renal function and, in case of continent diversions, provide good functional results. Increasingly, emphasis is placed on decreased hospital stay for patients who undergo various surgical procedures, underlining the need for technically safe procedures reflected in low perioperative and late complication rates [5]. Although continent urinary diversions may be of great psychological benefit to selected patients, they may be associated with different side-effects. Hyperchloremic metabolic acidosis can occur because of reabsorption of ammonium chloride and secretion of sodium bicarbonate by ileal tissue of the neobladder [6], [7]. Resection of part of the ileum for urinary diversion may also lead to vitamin B12 or folic acid deficiencies [8], [9].

Evaluating complications and functional results between different studies is hampered owing to different definitions of complication rates, continence and voiding dysfunction, and the different surgical techniques used. In this study we assessed early and late complication rates, functional results, and metabolic changes in the four different urinary diversions that we used between 1990 and 2005. We analysed the association of tumour stage, ASA score, age, and previous received pelvic radiotherapy with these variables.

Section snippets

Patients and methods

Between 1990 and 2005, 281 consecutive patients underwent a cystectomy with subsequent urinary diversion at our institute. Median age was 63 yr (range, 32–85).

Tumours were staged according to the International Union Against Cancer classification rules of 2002. Pathological stage (pT) was assigned according to the highest stage after diagnostic transurethral resection or cystectomy. In general patients with positive lymph nodes were treated with adjuvant or neoadjuvant chemotherapy according to

Patient characteristics

In total, 212 male patients and 69 female patients underwent cystectomy. Of these patients, 118 received an ileal conduit, 51 an Indiana pouch, 62 a neobladder, and 50 an SPCN. Patient characteristics according to type of diversion are summarised in Table 1. Of all female patients, 90% received a cutaneous diversion (ileal conduit and Indiana pouch combined), which 50% of the male population received. Patients with an orthotopic diversion (neobladder and SCPN combined) were younger than

Discussion

Cystectomy with subsequent urinary diversion is still associated with considerable complications. Reported rates and types of complications vary widely, and many series report on one type of diversion, which makes them hard to compare. To evaluate complication rates and functional results of the four most commonly used diversions, we report on all consecutive diversions performed in our institute.

The early (44%) and late complication rates (51%) at our institute are in the higher range of

Conclusions

Cystectomy with any subsequent diversion remains a procedure with considerable morbidity. High ASA score is associated with more early complications. Orthotopic diversions provide good functional results, but at the cost of more late complications compared with cutaneous diversions. Provided that a patients’ choice is based on a thorough preoperative consultation, we found no evidence that age, ASA score, positive lymph nodes, extravesical tumour growth, or previous radiotherapy were

Conflicts of interest

The authors have nothing to disclose.

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These authors contributed equally to this work.

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