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Urinary Diversion After Radical Cystectomy for Bladder Cancer: Options, Patient Selection, and Outcomes Richard K

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Urinary Diversion After Radical Cystectomy for Bladder Cancer: Options, Patient Selection, and Outcomes Richard K Reviews Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes Richard K. Lee1, Hassan Abol-Enein6, Walter Artibani7, Bernard Bochner2, Guido Dalbagni2, Siamak Daneshmand3, Yves Fradet9, Richard E. Hautmann10, Cheryl T. Lee4, Seth P. Lerner5, Armin Pycha8, Karl-Dietrich Sievert11, Arnulf Stenzl11, Georg Thalmann12 and Shahrokh F. Shariat1,13 1James Buchanan Brady Foundation, Department of Urology and Division of Medical Oncology, Weill Cornell Medical College, New York-Presbyterian Hospital, 2Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 3Keck School of Medicine, USC, University of Southern California (USC) Institute of Urology, Los Angeles, CA, 4Department of Urology, University of Michigan, Ann Arbor, MI, 5Department of Urology, Baylor College of Medicine, Houston, TX, USA, 6Department of Urology, Mansoura University, Mansoura, Egypt, 7Department of Urology, Verona University, Verona, 8Department of Pathology, Central Hospital of Bolzano, Bolzano, Italy, 9Urology Service, Department of Surgery, Laval University, Quebec City, Quebec, Canada, 10Department of Urology, University of Ulm, Ulm, 11Department of Urology, Universitätsklinikum Tübingen, Tübingen, Germany, 12Department of Urology, Inselspital, Bern, Switzerland, and 13Department of Urology, Medical University of Vienna, Vienna, Austria Extra-institutional Funding: None. Context of an external stoma and preservation of body image • The urinary reconstructive options available after radical without compromising cancer control. However, the cystectomy (RC) for bladder cancer are discussed, as are the patient must be fully educated and committed to the criteria for selection of the most appropriate diversion, and labour-intensive rehabilitation process. He must also be able the outcomes and complications associated with different to perform self-catheterisation if necessary. diversion options. • When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent Objective cutaneous reservoir may still offer the opportunity • To critically review the peer-reviewed literature on the for continence albeit one that requires obligate function and oncological outcomes, complications, and self-catheterisation. factors influencing choice of procedure with urinary • For patients who are not candidates for continent diversion, diversion after RC for bladder carcinoma. the ileal loop remains an acceptable and reliable option. Evidence Acquisition • A Medline search was conducted to identify original Conclusions articles, review articles, and editorials on urinary diversion • Both continent and incontinent diversions are available for in patients treated with RC. Searches were limited to the urinary reconstruction after RC. English language. • Orthotopic neobladders optimally preserve body image, • Keywords included: ‘bladder cancer’,‘cystectomy’,‘diversion’, while continent cutaneous diversions represent a reasonable ‘neobladder’,and ‘conduit’. alternative. • The articles with the highest level of evidence were selected • Ileal conduits represent the fastest, easiest, least and reviewed, with the consensus of all of the authors of complication-prone, and most commonly performed this paper. urinary diversion. Evidence Synthesis Keywords • Both continent and incontinent diversions are available for bladder cancer, outcome assessment (health care), patient urinary reconstruction after RC. In appropriately selected selection, radical cystectomy, urinary bladder neoplasms, patients, an orthotopic neobladder permits the elimination urinary diversion © 2013 BJU International | doi:10.1111/bju.12121 BJU Int 2014; 113: 11–23 Published by John Wiley & Sons Ltd. www.bjui.org wileyonlinelibrary.com Review Introduction and reviewed. Reviews and other secondary data sources Radical cystectomy (RC) for bladder cancer requires were excluded. reconstruction of the lower urinary tract. Ureterosigmoidostomy was the first widely used surgical technique for urinary diversion, providing an effective diversion using the anal sphincter for Evidence Synthesis continence. However, deterioration of renal function over time, Depending on the segment of bowel used to create a urinary metabolic complications, and the increased risk for secondary diversion, specific metabolic consequences may ensue, as malignancies limited its usefulness as a urinary diversion. outlined in Table 1. Postoperative bowel function may also be Subsequent surgical advances have led to major improvements in altered. The ideal urinary diversion has yet to be developed both functional outcomes and health-related quality of life (Table 2). Currently, urinary reconstruction falls into two (HRQOL). We discuss the available reconstructive options after general categories: incontinent diversions, such as the ileal RC for bladder cancer, criteria for selection, and the outcomes conduit, and continent diversions, including both cutaneous associated with each option. reservoirs and orthotopic reservoirs connected to the urethra. Evidence Acquisition Ureterosigmoidostomy A Medline search was conducted to identify original English One of the first urinary diversions using bowel included the language articles on urinary diversion after RC using the use of ureterosigmoidostomy, where the ureters were keywords ‘bladder cancer’,‘cystectomy’,‘diversion’, anastomosed to the sigmoid. Its major advantage is the ‘neobladder’, and ‘conduit’. In all, 105 articles were identified potential for spontaneous emptying of urine with stool, i.e. and those with the highest level of evidence were selected continence is maintained by the anal sphincter. Table 1 Primary indications and metabolic consequences for use of bowel segments. Bowel segment Primary indication Metabolic consequences Clinical symptoms Gastric • Children requiring diversion (exstrophy, pelvic Metabolic alkalosis (↓ K and Cl, • Haematuria-dysuria syndrome radiation) hypergastrinaemia) • Dehydration, lethargy, seizures, respiratory • Renal insufficiency distress Jejunum • Pelvic radiation Metabolic acidosis (↓ Na and Cl, ↑ K, • Dehydration, nausea/vomiting, weakness, • Deficient ureteric length azotaemia) lethargy, seizures • Compromised viability of other small or large bowel Ileum or ileal-colic reservoirs • Malignancies requiring removal of the bladder Metabolic acidosis (↑ Cl, ↓ bicarbonate, • Fatigue, anorexia, weight loss, diarrhoea, • Severe haemorrhagic cystitis azotaemia) polydipsia • Incontinence •B12 and fat-soluble vitamin deficiency • Diarrhoea, urinary calculi, cholelithiasis Colon (ureterosigmoidostomy) • Children requiring diversion (extrophy, pelvic Metabolic acidosis (↑ Cl, ↓ bicarbonate, • Fatigue, anorexia, weight loss, diarrhoea, radiation) azotaemia) polydipsia • No other bowel segment alternative • Pyelonephritis • Adenocarcinoma at anastomotic site Transverse colon conduit • Malignancies requiring removal of the bladder Metabolic acidosis (↑ Cl, ↓ bicarbonate, • Fatigue, anorexia, weight loss, diarrhoea, • Small bowel not practical azotaemia) polydipsia • Pyelonephritis • Adenocarcinoma at anastomotic site Table 2 Ideal characteristics of a urinary reservoir. Characteristic Comments Low-pressure system Higher internal pressure in the reservoir may overcome the external sphincter mechanisms that maintain continence. Stores a functional amount of urine (ª500 mL) Reliable, complete continence Detubularisation of intestinal segments limits the ability to generate a peristaltic pressure wave. These waves can contribute to incontinence. Complete voluntary control of voiding No absorption of urinary waste products by Minimises the likelihood of metabolic complications. the reservoir walls 12 © 2013 BJU International Urinary diversion after radical cystectomy for bladder cancer However, ureterosigmoidostomy is prone to detrimental upper technically able to catheterise the stoma over a lifetime cannot tract changes in patients over time, e.g. Ն10 years [1,2]. In be overemphasised. Although these diversions have been largely addition, the mixture of faecal and urinary streams predisposed supplanted by the orthotopic neobladder, they are still used patients to a higher risk of bowel adenocarcinoma [3,4]. Several when continence is desired in the setting of non-functional modifications of the ureterosigmoidostomy were developed to urethra or a positive intraoperative urethral margin obviating decrease the significant complication rate associated with the the ability to perform orthotopic diversion. procedure. The sigma rectum, or Mainz II pouch, consists of a Results have varied in different institutions. Holmes et al. [10], detubularised colon 6 cm both proximal and distal to the for example, reported on 112 patients undergoing a modified rectosigmoid junction, where the ureters are then implanted in Indiana pouch over a 14-year period in a single institution a non-refluxing fashion [5]. The objective of this pouch was to series. In all, 90% of patients had complications, with create a low-pressure reservoir to protect the upper tracts, incontinence representing the most common (28%) although the risk of adenocarcinoma still remained. complication. In all, 58% of complications were related to the Kock et al. [6,7] descried the use of an intussuscepted nipple efferent loop of the pouch, including stomal stenosis in 15% valve stabilised with permanent staples, whereupon the distal and difficulty with catheterisation in 10%. Other problems rectal segment is then
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