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