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