Factors influencing the choice of urinary diversion in patients undergoing radical cystectomy

Temporal Trends in Urinary Diversion among Patients Undergoing Radical Cystectomy Between 1986 and 2022: Experience at the University Medical Center Mainz with 2224 Cases

BACKGROUND

Analysis of temporal trends of urinary diversion (UD) and identification of predictive factors for continent urinary diversion (CUD) in patients with bladder cancer (BC) is scarce and data on large cohorts are missing. We aimed to describe longitudinal temporal trends and predictive factors for UD among patients with BC receiving radical cystectomy (RC).

PATIENTS AND METHODS

We retrospectively analysed institutional data collected from patients undergoing RC from 1986 to 2022 to describe changes in patients' characteristics and UD. Primary end points were patients' characteristics associated with type of UD. Logistic regression analysis was used to determine predictive factors for CUD.

RESULTS

In total, 2224 patients (77.16% male, 22.84% female) with a mean age of 66 years [standard deviation (SD), 10.64 years] were included. We observed an increase in mean age from 59.86 (10.8) years (1986-1990) to 69.85 (9.99) years (2016-2022) (p < 0.001). The proportion of CUD gradually declined from 43.72% (94/215; 1986-1990) to 18.38% (86/468; 2016-2022). Patients who were male [odds ratio (OR): 1.92, 95% confidence interval (CI): 1.43-2.57, p < 0.001), younger (OR: 0.88, 95% CI: 0.87-0.89, p < 0.001) and had no hydronephrosis prior to RC (OR: 2.2, 95% CI: 1.66-2.92, p < 0.001) were more likely to receive CUD.

CONCLUSIONS

We report the largest European single-center cohort of UD after RC, demonstrating a significant shift from CUD to IUD, accompanied by an increasing age. Finally, our data mirrors the development and extensive experience with the Mainz Pouch-I in the 1980's and 1990's together with other colon pouches.

Indiana Pouch Continent Cutaneous Urinary Diversion After Robotic-assisted Radical Cystectomy: A 16-Year Experience

BACKGROUND

Population-based practice patterns in the United States reveal continent diversions are only performed in 8%-10.4% of patients.1-4 Ideally, for patients undergoing radical cystectomy the choice of urinary diversion should be influenced by clinical factors and patient preference, with discussions surrounding quality of life. Unfortunately, receipt of continent diversion has been shown to be influenced by a plethora of other factors such as surgeon preference/training, geography, socioeconomic status, gender, and hospital volume.1-3 Thus, by providing detailed instruction and long-term follow-up, we hope to mitigate some of these disparities by changing the perceptions regarding feasibility and complications of continent diversions.

OBJECTIVE

To provide step-by-step instruction and to report long-term clinical outcomes in bladder cancer patients receiving an Indiana pouch continent cutaneous urinary diversion (CCUD) after robot-assisted radical cystectomy.

DESIGN, SETTING, AND PARTICIPANTS

After Institutional Review Board approval, a prospectively maintained bladder cancer database was queried for patients with T1-T4, N0-N1, M0 bladder cancer undergoing radical cystectomy with CCUD at a tertiary referral center from 2004 to 2020.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Complications at 30- and 90-day were recorded according to the Clavien-Dindo classification. Continence rates were recorded by chart review.

RESULTS AND LIMITATIONS

A total of 97 patients were included with a median follow-up of 93months. Clinically, 91.8% had ≤T2 disease and 29.9% received neoadjuvant chemotherapy. The median length of surgery was 8.0 hours, length of hospital stay was 8.3days, and urinary continence rate was 99.0%. The overall complication rate was 73.2% and 76.5% at 30- and 90-day, respectively. The major complication rate (Clavien III-V) was 17.5% at 30-day and 22.7% at 90-day. The most common major complications were abdominal infection and uretero-colonic stricture. The readmission rate was 21.4% and median overall survival was 108months.

CONCLUSION

CCUD provides exceptional functional outcomes with acceptable complication rates compared to other diversion types. CCUD is a reliable reconstructive option and with this step-by-step video as a reference, we hope it will be offered to more patients.

Association of Open vs Robot-Assisted Radical Cystectomy With Mortality and Perioperative Outcomes Among Patients With Bladder Cancer in Sweden

IMPORTANCE

Mortality rates resulting from bladder cancer have remained unchanged for more than 30 years. The surgical community has put hope in robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in an effort to improve surgical outcomes and bladder cancer survival without strong supporting evidence.

OBJECTIVE

To evaluate perioperative, safety, and survival outcome differences between RARC with ICUD and open radical cystectomy (ORC).

DESIGN, SETTING, AND PARTICIPANTS

This nationwide population-based cohort study used data from the Swedish National Register of Urinary Bladder Cancer and population-based Cause of Death Register, which includes clinical information on tumor characteristics, treatment, and survival and covers approximately 97% of patients with urinary bladder cancer in Sweden. All patients who underwent radical cystectomy for bladder cancer in any hospital between January 2011 and December 2018 were included. Follow-up data were collected until December 2019. Data analysis was conducted from June to December 2020.

EXPOSURES

RARC or ORC.

MAIN OUTCOMES AND MEASURES

The main outcomes were all-cause and cancer-specific mortality between RARC and ORC, compared using propensity score matching. Secondary outcomes were differences in perioperative outcomes after the different surgical approaches.

RESULTS

Throughout the observation period, 889 patients underwent RARC and 2280 patients underwent ORC at 24 Swedish hospitals. The median (IQR) age was 71 (66-76) years and 2386 patients (75.3%) were men. After a median (IQR) follow-up of 47 (28-71) months, the 5-year cancer-specific mortality rates were 30.2% (variance, 1.59) for ORC and 27.6% (variance, 3.12) for RARC, and the overall survival rates were 57.7% (variance, 2.46) for ORC and 61.4% (variance, 5.11) for RARC. In the propensity score-matched analysis, RARC was associated with a lower all-cause mortality (hazard ratio, 0.71; 95% CI, 0.56-0.89; P = .004). Compared with ORC, RARC was associated with a lower estimated blood loss (median [IQR] 150 [100-300] mL vs 700 [400-1300] mL; P < .001), intraoperative transfusion rate (odds ratio [OR], 0.05; 95% CI, 0.03-0.08; P < .001), and shorter length of stay (median [IQR], 9 [6-13] days vs 13 [10-17] days; P < .001), and with a higher lymph node yield (median [IQR], 20 [15-27] lymph nodes vs 14 [8-24] lymph nodes; P < .001) and 90-day rehospitalization rate (OR, 1.28; 95% CI, 1.02-1.60; P = .03). The RARC group, compared with the ORC group had lower risk of Clavien-Dindo grade III or higher complications (OR, 0.62; 95% CI, 0.43-0.87; P = .009).

CONCLUSIONS AND RELEVANCE

These findings suggest that compared with ORC, RARC with ICUD was associated with a lower overall mortality rate, fewer high-grade complications, and more favorable perioperative outcomes.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion

OBJECTIVE

To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use.

PATIENTS AND METHODS

A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC.

RESULTS

Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed.

CONCLUSIONS

For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Predictors of need for catheterisation and urinary retention after radical cystectomy and orthotopic neobladder in male patients

OBJECTIVES

To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors.

PATIENTS AND METHODS

Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3 catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention.

RESULTS

Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10 years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10 years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27 kg/m² ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention.

CONCLUSION

In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27 kg/m² are at significantly increased risk of retention and need for self-catheterisation.

Factors influencing intraoperative conversion from planned orthotopic to non-orthotopic urinary diversion during radical cystectomy

OBJECTIVES

To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy.

SUBJECTS AND METHODS

A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study.

RESULTS

Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p < 0.001). Oncologic reasons for intraoperative conversions were more common than technical reasons (58.3% vs 35.9%), in both robotic and open surgical techniques. The choice of surgical approach (open vs robotic) did not influence the rate of intraoperative conversion.

CONCLUSION

The factors influencing intraoperative decision not to perform neobladder are predominantly oncologic rather than technical. A clear understanding of the factors involved in influencing the intraoperative change in the urinary diversion plan may improve shared decision making in patients undergoing radical cystectomy in the future.

Functional Assessment of the Hautmann Ileal Neobladder with Chimney Modification Using Uroflowmetry and a Questionnaire

Urinary diversion reconstruction is essential after radical cystectomy and neobladder reconstruction is accepted as a fine option. This study included 51 patients, who underwent radical cystectomy with orthotopic neobladder reconstruction by a Hautmann ileal neobladder with chimney modification from 2006 to 2014. Functional outcomes were evaluated using a questionnaire and uroflowmetry. Perioperative complications were analyzed retrospectively. The mean follow-up period was 36.1 months. Eighty-six percent of patients voided without clean intermittent catheterization (CIC) assistance. CIC was used 1-2x per day or every time they voided in 8% and 6% of patients, respectively, and 71% of patients were continent. The percentages of patients who used 1, 2, 3-4, and ≥5 pads per day were 15%, 6%, 2%, and 6%, respectively. Daytime and nighttime continence were achieved in 86% and 69% of patients, respectively. Daily mucus leakage was reported in 69% of patients. The mean maximum neobladder capacity, voided volume, postvoid residual volume, and maximum flow rate were 413.2 mL, 370.6 mL, 43.7 mL, and 20.8 mL/s, respectively. Eighteen early and 5 late complications developed in 13 and 5 patients, respectively. Reoperations were needed in 7 patients. The Hautmann ileal neobladder with chimney modification provided satisfactory results regarding functional outcomes.

Orthotopic urinary diversion

PURPOSE OF REVIEW

Orthotopic urinary diversion has been performed for more than 30 years. Although it is considered to be the gold standard form of diversion in many centers of expertise, however it is uncommonly performed outside these institutions. The purpose of this article is to review the current indications and outcomes of orthotopic diversion with a focus on male patients and to explore potential barriers to wider dissemination of the technique.

RECENT FINDINGS

Approximately 75% of patients undergoing radical cystectomy today are candidates for orthotopic diversion and in the absence of absolute contraindications, very few patients chose to undergo an ileal conduit for personal reasons. In a recent quality of life study, the orthotopic neobladder was better than ileal conduit in terms of global health status and physical functioning. In a prospective randomized trial comparing a refluxing versus nonrefluxing neobladder, there was no difference in renal function after 3 years. There is currently insufficient evidence to suggest improved perioperative outcomes with the use of minimally invasive techniques.

SUMMARY

There are very few absolute contraindications for an orthotopic neobladder, which remains the gold standard form of diversion at many centers of expertise. Surgeon experience and thorough preoperative counseling with realistic expectations can ensure optimal outcomes and patient satisfaction.

Patient and disease-specific factors and their influence on urinary reconstruction choice at a referral center

PURPOSE

To evaluate potential socioeconomic and demographic factors that may influence or be associated with various types of urinary reconstruction (UR) following a radical cystectomy (RC) accounting for existing clinical variables.

METHODS

There were 828 patients that underwent a RC and UR between 2000 and 2013. After excluding patients that did not meet medical or surgical criteria for a continent urinary reconstruction (CUR-orthotopic neobladder or continent catheterizable pouch), there were 714 patients available for analysis. Socioeconomic and demographic data along with disease-specific variables were recorded preoperatively and analyzed to determine a correlation with a particular type of UR.

RESULTS

Non-continent urinary reconstruction (ileal conduit or cutaneous ureterostomies) and CUR accounted for 78.3 % (559/714) and 21.7 % (155/714) of UR following RC, respectively. On univariate analysis, younger age, marital status, employment status, type of insurance, ASA score, and preoperative glomerular filtration rate were significantly associated with CUR (p < 0.01). Travel distance, race, and education level were not factors for UR type. Additionally, there was no significant difference between males and females receiving a CUR. On multivariate analysis, older age [odds ratio (OR) 0.85, p < 0.01], marital status (OR 0.28, p < 0.01), insurance status (OR 0.22, p = 0.04), and higher ASA score (OR 0.50, p < 0.01) remained independent predictors of those less likely to receive a CUR.

CONCLUSION

Predictable socioeconomic and demographic influences exist between the choice of UR after RC. Increasing age corresponds to a decreasing likelihood of receiving a CUR. No significant difference was seen between men and women in undergoing a CUR.

A systematic review of factors influencing older adults' decision to accept or decline cancer treatment

BACKGROUND

Cancer is a disease that affects mostly older adults. Older adults often have other chronic health conditions in addition to cancer and may have different health priorities, both of which can impact cancer treatment decision-making. However, no systematic review of factors that influence an older cancer patient's decision to accept or decline cancer treatment has been conducted.

MATERIALS AND METHODS

Systematic review of the literature published between inception of the databases and February 2013. Dutch, English, French or German articles reporting on qualitative studies, cross-sectional, longitudinal observational or intervention studies describing factors why older adults accepted or declined cancer treatment examining actual treatment decisions were included. Ten databases were used. Two independent reviewers reviewed manuscripts and performed data abstraction using a standardized form and the quality of studies was assessed with the Mixed Methods Appraisal Tool.

RESULTS

Of 17,343 abstracts reviewed, a total of 38 studies were included. The majority focused on breast and prostate cancer treatment decisions and most studies used a qualitative design. Important factors for accepting treatment were convenience and success rate of treatment, seeing necessity of treatment, trust in the physician and following the physician's recommendation. Factors important for declining cancer treatment included concerns about the discomfort of the treatments, fear of side effects and transportation difficulties.

CONCLUSION

Although the reasons why older adults with cancer accepted or declined treatment varied considerably, the most consistent determinant was physician recommendation. Further studies using large, representative samples and exploring decision-making incorporating health literacy and comorbidity are needed.

Body image following radical cystectomy and ileal neobladder or conduit in korean patients

PURPOSE

The aim of this study was to compare the body images of patients who underwent radical cystectomy with an orthotopic ileal neobladder or an ileal conduit.

MATERIALS AND METHODS

A total of 114 adult patients who underwent radical cystectomy between March 2006 and December 2012 at a single institution, Ewha Womans University Mokdong Hospital in Korea, were evaluated in this retrospective chart-review study. Forty-two patients (29 orthotopic ileal neobladder and 13 ileal conduit) who completed questionnaires were included in the final analysis; the remaining patients were excluded. The patients were assessed with two questionnaires: the Korean version of the Body Image Scale (K-BIS) and the self-designed questionnaire.

RESULTS

The results did not differ significantly by age at surgery, time from surgery to survey, pathologic stage, grade, histologic subtype, education, residency, or Eastern Cooperative Oncology Group performance status, but did differ significantly by age at survey and sex. The mean summary score for K-BIS showed significant differences between the two groups (p=0.001). We found that patients who underwent an orthotopic ileal neobladder had a significantly better body image. The self-designed questionnaire score was not significantly different between the two groups (p=0.572).

CONCLUSIONS

In our retrospective analysis, patients who underwent orthotopic ileal neobladder had a superior body image compared with those who underwent an ileal conduit.

Population-based trends in urinary diversion among patients undergoing radical cystectomy for bladder cancer

What's known on the subject? and what does the study add?: Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high-volume and teaching hospitals are more likely to receive continent diversions.

OBJECTIVE

To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy (RC) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population-based cohort.

PATIENTS AND METHODS

Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time.

RESULTS

Overall, 55635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001-2002 to 9.4% in 2007-2008 (P < 0.001 for trend). Patients who were older (odds ratio [OR] 0.93; P < 0.001), female (OR 0.52; P < 0.001) and insured by Medicaid (OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching (OR 2.14; P < 0.001) and high-volume hospitals (OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non-teaching and medium/low-volume hospitals over time.

CONCLUSIONS

In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

Improving selection of appropriate urinary diversion following radical cystectomy for bladder cancer

Radical cystectomy represents the gold-standard of treatment for invasive bladder cancer. Following cystectomy, various options for urinary diversion may be offered to patients. This article represents an overview of the history of urinary diversion, explains the current selection criteria used at one of the most experienced bladder cancer centers worldwide, and provides an update on the current understanding of continence mechanisms. Furthermore, we review the current literature on quality of life for patients with different forms of urinary diversion. Excellent functional results can be achieved with continent forms of urinary diversion. It is important to consider the relative and absolute contraindications when choosing any form of urinary diversion. Proper patient selection and thorough standardized preoperative counseling is critical in achieving optimal results.